Indian Journal of Plastic Surgery
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Coverpage
January-April 2015
Volume 48 | Issue 1
Page Nos. 1-105

Online since Friday, April 17, 2015

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EDITORIAL  

Moving ahead p. 1
Mukund Jagannathan
DOI:10.4103/0970-0358.155257  
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ICON OF THE ISSUE Top

Dr. Suresh Raghunath Tambwekar: A man with a vision p. 2
Viraj S Tambwekar
DOI:10.4103/0970-0358.155258  
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PROF. MIRA SEN (BANERJEE) C.M.E. ARTICLE Top

Pressure ulcers: Current understanding and newer modalities of treatment p. 4
Surajit Bhattacharya, RK Mishra
DOI:10.4103/0970-0358.155260  
This article reviews the mechanism, symptoms, causes, severity, diagnosis, prevention and present recommendations for surgical as well as non-surgical management of pressure ulcers. Particular focus has been placed on the current understandings and the newer modalities for the treatment of pressure ulcers. The paper also covers the role of nutrition and pressure-release devices such as cushions and mattresses as a part of the treatment algorithm for preventing and quick healing process of these wounds. Pressure ulcers develop primarily from pressure and shear; are progressive in nature and most frequently found in bedridden, chair bound or immobile people. They often develop in people who have been hospitalised for a long time generally for a different problem and increase the overall time as well as cost of hospitalisation that have detrimental effects on patient's quality of life. Loss of sensation compounds the problem manifold, and failure of reactive hyperaemia cycle of the pressure prone area remains the most important aetiopathology. Pressure ulcers are largely preventable in nature, and their management depends on their severity. The available literature about severity of pressure ulcers, their classification and medical care protocols have been described in this paper. The present treatment options include various approaches of cleaning the wound, debridement, optimised dressings, role of antibiotics and reconstructive surgery. The newer treatment options such as negative pressure wound therapy, hyperbaric oxygen therapy, cell therapy have been discussed, and the advantages and disadvantages of current and newer methods have also been described.
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ORIGINAL ARTICLES Top

Anatomical study of anterior supramalleolar artery and its potential application to design a bi-foliate fasciocutaneous flap p. 17
Ji-Yin He, Shih-Heng Chen, Kannan Karuppiah Kumar, Zhi-Hong Fan, Jie Lao, Huey Tien
DOI:10.4103/0970-0358.155262  
Purpose: A further understanding of the anterior supramalleolar artery (ASMA) and its potential applications in reconstructive surgery. Materials and Methods: A total of 24 fresh lower limbs from fresh cadavers were injected with red latex for dissection. The type of origin, course, diameter of the pedicle, and the distance between the origin of the ASMA from the anterior tibial artery to the extensor retinaculum (O-R) were recorded. Bi-foliate fasciocutaneous flaps were harvested using the branches of the ASMA. Results: We found four types of origin of the ASMA, and we have accordingly classified them into four types. 10 of them were type A, 7 were type B, 6 were type C and 1 was type D. The mean O-R (origin of ASMA to retinaculum) distance was 2.0 ± 0.8 cm. The diameter of the medial branch (D1), the diameter of the lateral branch (D2), and the diameter of artery stem (D3) (only in type A) were 1.0 ± 0.2 mm, 0.8 ± 0.3 mm, 1.1 ± 0.2 mm, respectively. The mean pedicle length of the lateral flap (L1) and medial flap (L2) were 5.1 ± 1.0 cm and 3.7 ± 0.6 cm, respectively. Conclusions: The ASMA exists constantly with four different types of origin. Its sizable diameter and lengthy pedicle make it suitable for bi-foliate fasciocutaneous flap transfer.
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Effects of limited access dressing in chronic wounds: A biochemical and histological study p. 22
Thittamaranahalli Muguregowda Honnegowda, Pramod Kumar, EG Padmanabha Udupa, Anurag Sharan, Rekha Singh, Hemanth K Prasad, Pragna Rao
DOI:10.4103/0970-0358.155263  
Background: Negative pressure wound therapy has emerged as an attractive treatment modality for the management and healing of chronic ulcers. Though numerous clinical studies are available, there is a lack of biochemical and histological studies evaluating the healing of chronic wounds. Materials and Methods: In the present study, a total 60 patients were divided into two groups: Limited access dressing (LAD) group (n = 30) and conventional dressing group (n = 30). Various biochemical parameters such as hydroxyproline, total protein and antioxidants such as reduced glutathione (GSH), glutathione peroxidase (GPx), catalase (CAT) and oxidative biomarker malondialdhyde (MDA) are measured in the granulation tissue. Histologically amount of inflammatory infiltrate, angiogenesis, and collagen deposition are studied to assess wound healing. Results: Patients treated with LAD have shown significant increase in the mean (±standard deviation) hydroxyproline (77.3 ± 30.1 vs. 32.3 ± 16.18; P = 0.026), total protein (13.89 ± 9.0 vs. 8.9 ± 4.59; P = 0.004), GSH (7.4 ± 1.91 vs. 5.1 ± 1.28; P = 0.039), GPx (122.3 ± 59.3 vs. 88.7 ± 34.11; P = 0.030), CAT (1.80 ± 1.14 vs. 0.9 ± 0.71; P = 0.002) and decrease in MDA (13.4 ± 5.5 vs. 8.6 ± 3.8; P = 0.004). Histological study showed comparatively fewer inflammatory cells, increased and well organised collagen bundles, and more angiogenesis in the LAD group when compared with that with conventional dressing after 10 days of treatment. Conclusion: In the present study, we have found beneficial effect of newer intermittent negative pressure therapy in combination with moist environment (LAD) on chronic wound healing by increasing collagen deposition and angiogenesis; and reducing oxidative stress and inflammatory infiltrate.
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COMMENTARY Top

Biochemical and histological study of granulation tissue to evaluate the effect of limited access dressing in chronic wounds: A comparative study p. 28
Air Mshl Anil Behl, Pauline Babu, Pallab Chatterjee
DOI:10.4103/0970-0358.155264  
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ORIGINAL ARTICLES Top

A new paradigm in facial reanimation for long-standing palsies? p. 30
Rajeev B Ahuja, Pallab Chatterjee, Rajat Gupta, Prabhat Shrivastava, Gaurav K Gupta
DOI:10.4103/0970-0358.155265  
Background: A chance observation of return of excellent facial movement, after 18 months following the first stage of cross-face nerve grafting, without free functional muscle transfer, in a case of long-standing facial palsy, lead the senior author (RBA) to further investigate clinically. Patients and Methods: This procedure, now christened as cross-face nerve extension and neurotization, was carried out in 12 patients of very long-standing facial palsy (mean 21 years) in years 1996-2011. The mean patient age and duration of palsy were 30.58 years and 21.08 years, respectively. In patients, 1-5 a single buccal or zygomatic branch served as a donor nerve, but subsequently, we used two donor nerves. The mean follow-up period was 20.75 months. Results: Successive patients had excellent to good return of facial expression with two fair results. Besides improved smile, patients could largely retain air in the mouth without any escape and had improved mastication. No complications were encountered except synkinesis in 1 patient. No additional surgical procedures were performed. Conclusion: There is experimental evidence to suggest that neurotization of a completely denervated muscle can occur by the formation of new ectopic motor end plates. Long-standing denervated muscle fibres eventually atrophy severely but are capable of re-innervation and regeneration, as validated by electron microscopic studies. In spite of several suggestions in the literature to clinically validate functional recovery by direct neurotization, the concept remains anecdotal. Our results substantiate this procedure, and it has the potential to simplify reanimation in longstanding facial palsy. Our work now needs validation by other investigators in the field of restoring facial animation.
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Utility of arteriovenous loops before free tissue transfer for post-traumatic leg defects p. 38
Sheeja Rajan Thekkayil Mambally, Krishnakumar Krishnan Santha
DOI:10.4103/0970-0358.155266  
Crush injuries of severe magnitude involving lower limbs require complex bone and soft tissue reconstructions in the form of microvascular free tissue transfers. However, satisfactory recipient vessels are often unavailable in the leg due to their vulnerability to trauma and post traumatic vessel disease (PTVD), which extends well beyond the site of original injury. In such situations, healthy recipient vessels for free flap anastomosis can be made available by constructing temporary arteriovenous loops with saphenous vein grafts, anastomosed to corresponding free flap vessels. Our study included 7 patients with severe crush injuries of leg due to rail and road traffic accidents. Long and short saphenous vein grafts were anastomosed to Femoral artery in the subsartorial canal in 2 cases and to large muscular branches and accompanying veins in rest of the cases. Free flap transfers were performed in the same sitting in 6 cases. One case showed insufficient dilatation of the vein loop and hence free flap transfer was staged. Free Latissimus dorsi, Gracilis and Rectus abdominis flaps were performed. There were two cases of flap necrosis - one in the case of a pathologic vein graft with staged flap transfer which showed vein thrombosis on re exploration. The other case of flap failure was caused by a hematoma underneath the flap. In another patient, secondary haemorrhage occurred on day 18, without any consequence to the flap. All the other cases had complete free flap survival. We consider the use of single stage arteriovenous loops, a valuable tool to increase the applications of free flap, whenever healthy recipient vessels are not available in the periphery of the trauma.
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Anatomic basis for an algorithmic approach for free fibula flap donor side selection in composite oro-mandibular defects p. 43
Mohit Sharma, Abhijeet Wakure, Krishnakumar Thankappan, Jimmy Mathew, Dayanand Jairaj, Raghuveer Reddy Dudipala, Subramania Iyer
DOI:10.4103/0970-0358.155268  
Introduction: Head and neck oncological resections may result in composite oro-mandibular defects involving the oral mucosa (lining), mandibular bone and the skin (cover). Reconstructive options for such defects have evolved over a period. Free fibula flap reconstruction is currently accepted the world over as the gold standard for oro-mandibular defect reconstruction. Existing literature provides conflicting views about the use of a particular side and orientation of the fibula flap for achieving the optimal outcome. The purpose of this study is to confirm anatomically the effect of bone, soft tissue and vessel orientation on the ease of doing reconstruction. Materials and Methods: This is a cadaveric study. A mandibular model with a defect was used. This was pre plated to maintain continuity. Composite fibula flaps of the same dimension were harvested from both legs of a fresh cadaver. The harvested flaps were used to reconstruct the mandibular defect in different orientations and the best configuration for each reconstructive requirement was assessed. Results: Keeping the peroneal surface for plating, that is, facing outwards, four different configurations of the fibula flap are possible for a given mandibular defect. With a posterior vascular pedicle ipsilateral fibula is suitable for skin cover and contralateral for mucosal lining and the reverse for an anteriorly placed pedicle. Conclusion: The algorithm based selection of appropriate sided fibula flap facilitates complex mandibular reconstruction by placing the right kind of tissue at the right place and helps in reducing the donor site morbidity by allowing the surgeon to harvest only the required amount of skin.
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Comparative study of Mirs ' (Mushtaq and Shabir) technique of prepuce preserving minimally invasive urethroplasty with Snodgrass urethroplasty for repair of distal hypospadias without chordee…A prospective study p. 48
Mushtaq Mir, Shabir Ahmad Mir, Muddassir Shahdhar, Mumtazdin Wani, Hakim Adil Moheen, Jahangeer Ahmad Bhat
DOI:10.4103/0970-0358.155269  
Background: There is no single, universally applicable technique for hypospadias repair and numerous techniques have been practised from time to time. We compare the results of our new technique (Mirs' technique also called Mush & Shab's technique) to Snodgross urethroplasty. Mirs' technique is a modified version of Thiersch-Duplay urethroplasty. Material and Methods: This prospective comparative study was carried out in a tertiary care hospital of Northern India over a period of 3 years from March 2010 to March 2013 and included 120 patients of anterior (distal penile, subcoronal, coronal and glanular) hypospadias without chordee. They underwent either Mirs' technique (group 1 n = 60) or Snodgrass technique (group 2 n = 60). Follow-up was at 1-week, 1-month, 3 months and 6 months. Results: The mean operative time was 55 min (range: 43-70 min) in group 1 and 71.9 min (range: 60-81 min) in group 2 (P < 0.001). Urethrocutaneous fistula developed in two and four patients in group 1 and 2, respectively. Fistula closure was done at least 3 months postoperatively, and there was no significant difference in success rate between the two groups. Three cases of glanular dehiscence were detected (one in group 1 and two in group 2); the patient from group 1 had a successful repair using the already preserved prepuce. Conclusion: Mirs' modification of Thiersch-Duplay technique for distal hypospadias is a time saving procedure with a lower overall complication rate. Valuable local tissue is preserved to deal with any complication that may occur. Analgesic requirement was significantly lower in this minimally traumatic technique. As it is less time consuming, simple and easy to learn with a short learning curve, this technique deserves application in cases of distal hypospadias.
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Innovative technique: Distal venous cannulation for salvaging free flap venous thrombosis by heparinised saline irrigation p. 54
G. D. S. Kalra, Devidutta Mohanty, Ritesh Jain
DOI:10.4103/0970-0358.155270  
Introduction: Successful free tissue transfer depends on a multitude of factors, and adequate drainage of venous blood is one of the most critical part of successful free tissue transfers. Material and Methods: We report 6 cases of microvascular free flaps used for covering various defects, which developed venous congestion, that were salvaged with heparinised saline irrigation through the distal end of the congested vein by the help of an intravenous cannula. The irrigation was continued for 5 days. Results: All the flaps were successfully salvaged. Conclusion: This method has potential applications in situations for successful salvage of free tissue transfer particularly due to venous thrombosis.
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Role of platelet-rich plasma in chronic alopecia areata: Our centre experience p. 57
Sukhbir Singh
DOI:10.4103/0970-0358.155271  
Aim: The aim of the study was to evaluate the efficacy of platelet-rich plasma (PRP) in the treatment of chronic alopecia areata (AA). Material and Methods: This is a prospective study that was conducted at Kamal Hospital, Kaushambi in which 20 patients who attended the outpatient department were enrolled for the study. All the patients had h/o patches and taken various line of treatments for a duration of 2 years. All the patients were biopsy-proven positive for AA disease. There was no randomisation done since all of them were healthy young adults. The patients'age ranged from 25 to 35 years, and none of them had any co-morbidities. Results: Of 20 patients, only one patient had a relapse. None of the patients had any side effects, and all of them tolerated the procedure well. Conclusion: We wish to conclude that PRP has a definite role in treating AA infections. However, still more long-term follow-up, studies are required for further validation of results and labelling it as a 100% cure for people suffering from AA with recurrences which are so common.
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REFLECTIONS Top

A review of 48 patients after bear attacks in Central India: Demographics, management and outcomes p. 60
Surendra B Patil, Nikunj B Mody, Satish M Kale, Sonali D Ingole
DOI:10.4103/0970-0358.155267  
Introduction: Bear attacks though relatively rare are frequent enough to be of concern for those who are in bear habitats. Our centre at Nagpur, being surrounded by dense forests from all the sides, treats a large number of victims. Aim: The aim was to document the injuries, management and the potential complications of bear attacks. Materials and Methods: We reviewed the records of 48 consecutive patients who were treated in our department from January 2006 to December 2013 for bear attacks. Outcome: The majority of patients were referred 24-48 h post-attack. All but two patients had involvement of either the face or scalp. Involvement of eyes, mandible, facial nerve, was common. Reconstruction included simple suture of lacerations to management of complex compound injuries with three-dimensional defects. Thirteen patients developed infection. Conclusion: Bear attack victims need a multidisciplinary approach. Early broad spectrum antibiotics, anti-rabies prophylaxis and irrigation and debridement of the wound are needed. We advise early referral to tertiary treatment centres.
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REVIEW ARTICLES Top

Smart apps for the smart plastic surgeon Highly accessed article p. 66
Aniketh Venkataram, Sunderraj Ellur, Abha Rani Kujur, Vijay Joseph
DOI:10.4103/0970-0358.155273  
Smartphones have the ability to benefit plastic surgeons in all aspects of patient care and education. With the sheer number of applications available and more being created everyday, it is easy to miss out on apps which could be of great relevance. Moreover, the range of android applications available has not been extensively discussed in the literature. To this end, we have compiled an exhaustive list of android smartphone applications, which we feel can help our day to day functioning. The apps have been extensively reviewed and neatly described along with all their potential uses. In addition, we have made an effort to highlight 'non-medical' or efficiency apps which can improve departmental functioning. These apps have not been described in prior articles, and their functionality might not be known to all. We believe that the technology savvy plastic surgeon can make maximum use of these apps to his benefit.
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IDEAS AND INNOVATIONS Top

A simple and rapid method of repeated tie over dressing p. 75
Hardeep Singh, Aditya Khazanchi, Sanjay Mahendru, Vimalendu Brajesh, Sukhdeep Singh, S Krishnan
DOI:10.4103/0970-0358.155274  
Tie overdressing is commonly used to secure the graft against the raw surface and prevent loss due to of hematoma or seroma. A conventional tie over dressing with silk sutures, is a useful method of securing the graft to raw area. Refixation is difficult when repeated tie over dressings are needed. We assessed a low cost repeated tie over dressing method using sterile sample collection containers and silk suture threads in eight patients. After the graft is applied on the bed, tie-over stitches are taken, and paraffin gauze is applied over with adequate padding; the tie over sutures are passed through the container and the lid is tightened over it to complete the dressing. The lid can be unscrewed easily at any time to inspect the graft and can be easily reapplied in the outpatient department. The skin graft take in all the patients was complete without any seroma or hematoma. A novel and low-cost tie over dressing that enables simple fixation of the dressing, to maintain proper position of grafts that require repeated fixation is reported here.
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A novel and innovative technique of using a disposable syringe and mesh for harvesting fat for structural fat grafting p. 79
BC Ashok, Pradeep Kumar Nagaraj, YN Ananteshwar, V Srikanth
DOI:10.4103/0970-0358.155275  
Background: Successful restoration of structure and function using autologous free fat grafts has remained elusive. Review of literature shows that various harvesting and preparation techniques have been suggested. The goal of these techniques is to obtain greater adipocyte cell survival and consequently more reliable clinical results. Materials and Methods: In our technique, a piece of mesh is kept at one end of the lipoaspiration syringe, which is then connected to the Suction pump. As one syringe fills, it is replaced by another one until the required amount of fat is obtained. Results: By using a polypropylene mesh in our technique, we can separate the transfusate from the harvested fat graft during harvesting itself. The fat graft thus obtained is dense and concentrated, with fewer impurities. Conclusion: Hence, we recommend our technique as a reliable method for extracting sterile emulsified fat in an economical way.
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CASE REPORTS Top

Successful pregnancy "during" pedicled transverse rectus abdominis musculocutaneous flap for breast reconstruction with normal vaginal delivery p. 81
Siew Cheng Chai, Shahlini Umayaal, Arman Zaharil Mat Saad
DOI:10.4103/0970-0358.155276  
A transverse rectus abdominis myocutaneous (TRAM) flap is a popular choice for breast reconstruction. Pregnancies in women following a TRAM flap present concerns regarding both safety and the integrity of the abdominal wall. We report a case of a patient who was pregnant during immediate breast reconstruction with pedicled TRAM flap and had a successful spontaneous vaginal delivery. We also conducted a literature review using PubMed on pregnancy post TRAM flap, type of reconstruction, timing of pregnancy after TRAM flap, complication, and mode of delivery, which are summarised in this report. We concluded that patients may have safe pregnancies and normal deliveries following TRAM flap breast reconstruction regardless of the time frame of pregnancy after the procedure. Therefore, TRAM flaps can continue to be a reconstruction option, even in women of childbearing age.
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Revision breast and chest wall reconstruction in Poland and pectus excavatum following implant complication using free deep inferior epigastric perforator flap p. 85
Dimitrios Dionyssiou, Efterpi Demiri, Georgios Batsis, Leonidas Pavlidis
DOI:10.4103/0970-0358.155277  
This study aims to present the case of a female patient with Poland's syndrome and pectus excavatum deformity who underwent breast and chest wall reconstruction with a pre-shaped free deep inferior epigastric perforator flap. A 57-year-old female patient with Poland's syndrome and pectus excavatum presented with a Baker III capsular contracture following a previously performed implant-based right breast reconstruction. After a chest and abdominal CT angiography, she was staged as 2A1 chest wall deformity according to Park's classification and underwent implant removal and capsulectomy, followed by a pre-shaped free abdominal flap transfer, providing both breast reconstruction and chest wall deformity correction in a single stage operation. Post-operative course was uneventful, and the aesthetic result remains highly satisfactory 24 months after surgery. Deep inferior epigastric free flap represents an interesting reconstructive solution when treating Poland's syndrome female patients with chest wall and breast deformities.
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Management of post midface distraction occlusal discrepancy using temporary anchorage devices in a cleft patient p. 89
NK Koteswara Prasad, Syed Altaf Hussain, Arun B Chitharanjan, Jyotsna Murthy
DOI:10.4103/0970-0358.155278  
Open bite deformity following a successful midface advancement by distraction osteogenesis is a common complication. Temporary anchorage devices can be deployed during the distraction and post-distraction settling phases for restoring the occlusion even in severe cases. The following report describes the management of severe anterior open bite following maxillary distraction.
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LETTERS TO EDITOR Top

Parotid duct cyst in a child p. 92
Mehmet Dadaci, Gökhan Tuncbilek, Bilsev Ince, Fatma Bilgen
DOI:10.4103/0970-0358.155279  
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A simple and safe penile tourniquet p. 93
Devendra Kumar Gupta, Shruti Devendra
DOI:10.4103/0970-0358.155280  
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Peroneal muscle eversion technique for fibula flap p. 95
Dushyant Jaiswal, Yadav Prabha, Vinay Kant Shankhdhar, Puranik Prashant, Gujjulannavar Rajendra, Raghuvirsinh Solanki
DOI:10.4103/0970-0358.155281  
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A novel method of marking nipple areola complex in gynaecomastia surgery  Highly accessed article p. 96
Shabeer Ahmad Wani, Sari M Rabah, Sara AlFadil, Nieves Vega Saglam
DOI:10.4103/0970-0358.155282  
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Simple ways to improve undergraduate plastic surgery education p. 96
Nigel Yong Boon Ng, Mark Twoon
DOI:10.4103/0970-0358.155283  
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Diverse classification systems for maxillectomy defects: Simplifying or complicating the treatment plan? p. 98
Himanshi Aggarwal, Prashanti Eachempati, Pradeep Kumar
DOI:10.4103/0970-0358.155284  
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A different perspective for creating fistula p. 99
Sahin Iscan, Habib Cakir, Ismail Yurekli, Mert Kestelli
DOI:10.4103/0970-0358.155285  
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Reply to the letter to editor p. 100
Parag Sahasrabudhe
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The ulnar digital artery perforator flaps p. 101
Nikhil S Panse
DOI:10.4103/0970-0358.155287  
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A novel wiring technique in mandibular condylar fracture: customised interdental wire hooks p. 102
Amita Rani, Jitender Dabas, Sujata Mohanty
DOI:10.4103/0970-0358.155288  
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Anatomical variation of superficial radial nerve during free radial forearm flap harvest p. 104
Vinay K Shankhdhar, Prabha S Yadav, Jaiswal Dushyant, Selva S R Sakthipalan
DOI:10.4103/0970-0358.155289  
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