The perforator-based flaps in the sacral and ischial region is designed according to the localization of perforators that penetrate the gluteus maximus muscle, reach the intra-fascial and supra-fascial planes with the overlying skin forming a rich vascular plexus. The perforator-based flaps described in this article are highly vascularized, have minimal donor site morbidity, and do not require the sacrifice of the gluteus maximus muscle. In a period between April 2008 and March 2009, six patients with sacral pressure sore were reconstructed with propeller flap method based on superior gluteal and parasacral artery perforators. One flap loss was noted. Three cases of ischial pressure sore were reconstructed with longitudinal propeller flap cover, based on inferior gluteal artery perforator. One flap suffered wound infection and dehiscence. Two cases of pilonidal sinus were reconstructed with propeller flap based on parasacral perforators. Both the flaps survived without any complications. Donor sites were closed primarily. In the light of this, they can be considered among the first surgical choices to re-surface soft tissue defects of the sacral and ischial regions. In the series of 11 patients, two patients (18%) suffered complications.

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Background: The tenuous blood supply of traditional flaps for wound cover combined with collateral damage by sacrifice of functional muscle, truncal vessels, or nerves has been the bane of reconstructive procedures. The concept of perforator plus flaps employs dual vascular supply to flaps. By safeguarding perforators along with supply from its base, robust flaps can be raised in diverse situations. This is achieved while limiting collateral damage and preserving nerves, vessels, and functioning muscle with better function and aesthesis. Materials and Methods: The perforator plus concept was applied in seven different clinical situations. Functional muscle and fasciocutaneous flaps were employed in five and adipofascial flaps in two cases, primarily involving lower extremity defects and back. Adipofascial perforator plus flaps were employed to provide cover for tibial fracture in one patients and chronic venous ulcer in another. Results: All flaps survived without any loss and provided long-term stable cover, both over soft tissue and bone. Functional preservation was achieved in all cases where muscle flaps were employed with no clinical evidence of loss of power. There was no sensory loss or significant oedema in or distal to the flap in both cases where neurovascular continuity was preserved during flap elevation. Fracture union and consolidation were satisfactory. One patient had minimal graft loss over fascia which required application of stored grafts with subsequent take. No patient required re-operation. Conclusions: Perforator plus concept is holistic and applicable to most flap types in varied situations. It permits the exercise of many locoregional flap options while limiting collateral functional damage. Aesthetic considerations are also addressed while raising adipofascial flaps because of no appreciable donor defects. With quick operating times and low failure risk, these flaps can be a better substitute to traditional flaps and at times even free tissue transfers.

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Background: The reconstruction of complex thoraco-abdominal defects following tumour ablative procedures has evolved over the years from the use of pedicle flaps to free flaps. The free extended anterolateral thigh flap is a good choice to cover large defects in one stage. Materials and Methods: From 2004 to 2009, five patients with complex defects of the thoracic and abdominal wall following tumour ablation were reconstructed in one stage and were studied. The commonest tumour was chondrosarcoma. The skeletal component was reconstructed with methylmethacrylate bone cement and polypropylene mesh and the soft tissue with free extended anterolateral thigh flap. The flaps were anastomosed with internal mammary vessels. The donor sites of the flaps were covered with split-skin graft. Result: All the flaps survived well. One flap required re-exploration for venous congestion and was successfully salvaged. Two flaps had post operative wound infection and were managed conservatively. All flap donor sites developed hyper-pigmentation, contour deformity and cobble stone appearance. Conclusion: Single-stage reconstruction of the complex defects of the thoraco-abdominal region is feasible with extended anterolateral thigh flap and can be adopted as the first procedure of choice.

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We report a case involving a 45-year-old woman, who presented with an axillary mass 10 years after bilateral cosmetic augmentation mammaplasty. A lump was detected in the left axilla, and subsequent mammography and magnetic resonance imaging demonstrated intracapsular rupture of the left breast prosthesis. An excisional biopsy of the left axillary lesion and replacement of the ruptured implant was performed. Histological analysis showed that the axillary lump was lymph nodes containing large amounts of silicone. Silicone lymphadenopathy is an obscure complication of procedures involving the use of silicone. It is thought to occur following the transit of silicone droplets from breast implants to lymph nodes by macrophages and should always be considered as a differential diagnosis in patients in whom silicone prostheses are present.

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Background: The knowledge regarding the structural details of deep fascia remains inadequate. It was described to be relatively avascular having predominantly protective function. Anatomical and surgical studies revealed that it had associated vascular arcade and hence incorporated it to ascertain additional vascularity to the flaps. However, not much importance has been directed towards the detailed study of the various constituents of deep fascia in order to explain its physiological and clinical implications. Therefore, this study was undertaken to unveil these details. Materials and Methods: Fifty fresh specimens of human deep fascia overlying the gastrocnemius muscle were analyzed regarding the (i) vasculature, (ii) matrix, and (iii) other structural elements. The deep fascia was procured in three forms; (a) both the layers, (b) superficial layer, and (c) deep layer. Detail study was conducted by light, confocal, and electron microscopy. Results: Under light microscopy, blood vessels including capillaries were seen associated with both the layers. Perforators traversing the intra-fascial plane could be visualized. Confocal microscope optical sections showed well-organized bright fluorescent collagen fibers and nuclei of various cells. Electron microscopic evaluation revealed many interesting constituents which are relatively unknown to the anatomist and clinicians. There were arterioles, capillaries, venules, lymphatics, nerves, mast cells, and myofibroblasts apart from collagen and elastic fibers. Conclusion: The detail structural analysis of deep fascia provided the clue to its rich vascularity and other structural constituents. They all contribute to enhance the vascularity and maintenance of the physiological functions of fasciocutaneous, adipofascial, and fascial flaps, frequently used for reconstructions. Thus, incorporation of deep fascia in the flaps during reconstruction is highly beneficial for ensuring optimal vascularity.

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The gracilis muscle is a Class II muscle that is often used in free tissue transfer. The muscle has multiple secondary pedicles, of which the first one is the most consistent in terms of position and calibre. Each pedicle can support a segment of the muscle thus yielding multiple small flaps from a single, long muscle. Although it has often been split longitudinally along the fascicles of its nerve for functional transfer, it has rarely been split transversely to yield multiple muscle flaps that can be used to cover multiple wounds in one patient without subjecting him/her to the morbidity of multiple donor areas .

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An ulnar digital artery perforator flap was used for little finger reconstruction. The flap has a reliable blood supply, being perfused by a constant sizeable perforator. This paper describes a study of a cadaveric dissection with methylene blue dye that was conducted to prove the rationality and reliability of the blood supply. The position of the perforator is confirmed intraoperatively by an exploratory incision before committing to the distal incision. The flap used to cover the flexor aspect of the little finger in three cases yielded positive results. To our knowledge, a digital artery perforator flap of this nature is unprecedented. We propose to call this flap the B.J. Flap after our institute.

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Background: The objective of this study was to prove that there is no significance to the donor side (right or left) of the free fibula osteocutaneous flap (FFOCF) in the reconstruction of complex oromandibular defects (COMD) and proper flap planning, designing and tailoring are important in reconstructing different types of COMD after tumour-ablative surgery. Materials and Methods: Three hundred and eighty-six consecutive patients who where reconstructed with FFOCF for COMD from Jan 2005 to Dec 2009 over a period of 5 years were studied. Except in seven patients, all fibula flaps were harvested from the left leg as per convenience and to facilitate a simultaneous, two-team approach. Depending on the condition of the neck vessels, vascular anastomosis was performed on the right or the left side, irrespective of the side of the defect. Results: Complete flap survival was seen in 334 patients (86.52%). Superficial skin necrosis was seen in 20 patients, and was managed conservatively (5.18%). Partial flap loss was seen in 20 patients (5.18%). There were 39 re-explorations. Complete flap loss was seen in 12 patients (3.10%). Conclusion: We found no significance in terms of the results as far as the side of flap donor leg or primary defect were concerned. Flap tailoring in terms of meeting the tissue requirement and vessel orientation were rather more important.

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Objective: To assess the incidence of cleft lip and palate defects in the state of Andhra Pradesh, India. Design Setting: The study was conducted in 2001 in the state of Andhra Pradesh, India. The state has a population of 76 million. Three districts, Cuddapah, Medak and Krishna, were identified for this study owing to their diversity. They were urban, semi-urban and rural, respectively. Literacy rates and consanguinity of the parents was elicited and was compared to national averages to find correlations to cleft births. Type and side of cleft were recorded to compare with other studies around the world and other parts of India. Results: The birth rate of clefts was found to be 1.09 for every 1000 live births. This study found that 65% of the children born with clefts were males. The distribution of the type of cleft showed 33% had CL, 64% had CLP, 2% had CP and 1% had rare craniofacial clefts. Unilateral cleft lips were found in 79% of the patients. Of the unilateral cleft lips 64% were left sided. There was a significant correlation of children with clefts being born to parents who shared a consanguineous relationship and those who were illiterate with the odds ratio between 5.25 and 7.21 for consanguinity and between 1.55 and 5.85 for illiteracy, respectively. Conclusion: The birth rate of clefts was found to be comparable with other Asian studies, but lower than found in other studies in Caucasian populations and higher than in African populations. The incidence was found to be similar to other studies done in other parts of India. The distribution over the various types of cleft was comparable to that found in other studies.

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The face is a vital component of one's personality and body image. There are a vast number of variables that influence recovery and rehabilitation from acquired facial trauma many of which are psychological in nature. The present paper presents the various psychological issues one comes across in facial trauma patients. These may range from body image issues to post-traumatic stress disorder symptoms accompanied by anxiety and depression. Issues related to facial and body image affecting social life and general quality of life are vital and the plastic surgeon should be aware of such issues and competent to deal with them in patients and families.

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Rhinoscleroma is a chronic granulomatous condition of the nose and other structures of the upper respiratory tract. Infection by the bacterium Klebsiella rhinoscleromatis is said to be the cause. A female patient aged 45 years, presented with a past history of trauma to the nose and swelling on her nose since last 1 year. There was nasal asymmetry and internal nasal examination showed a septal swelling protruding to the right nasal cavity with hypertrophied nasal mucosa and inferior turbinate. Open tip rhinoplasty approach was used to excise the mass, which examined pathologically revealing a rhinoscleroma, fibrotic infiltrative stage.

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Background: The pedicled TRAM flap has been a workhorse of autologous breast reconstruction for decades. However, there has been a rising concern about the abdominal wall donor site morbidity with the use of conventional TRAM flap. This has generally been cited as one of the main reasons for resorting to "abdominal wall friendly" techniques. This study has been undertaken to assess the abdominal wall function in patients with pedicled TRAM flap breast reconstruction. The entire width of the muscle and the overlying wide disk of anterior rectus sheath were harvested with the TRAM flap in all our patients and the anterior rectus sheath defect was repaired by a Proline mesh. Materials and Methods: Abdominal wall function was studied in 21 patients who underwent simultaneous primary unipedicled TRAM flap reconstruction after mastectomy for cancer. In all the patients, the abdominal wall defect was repaired using wide sheet of Proline mesh both as inlay and onlay. The assessment tools included straight and rotational curl ups and a subjective questionnaire. The abdominal wall was also examined for any asymmetry, bulge, or hernia. The minimal follow-up was 6 months postoperative. The objective results were compared with normal unoperated volunteers. Results and Conclusions: The harvesting the TRAM flap certainly results in changes to the anterior abdominal wall that can express themselves to a variable degree. A relatively high incidence of asymptomatic asymmetry of the abdomen was seen. There was total absence of hernia in our series even after a mean follow-up period of 15.5 months. A few patients were only able to partially initiate the sit up movement and suffered an important loss of strength. In most patients, synergists took over the functional movement but as the load increased, flexion and rotation performances decreased. The lack of correlation between exercise tests and the results of the questionnaire suggests that this statistically significant impairment was functionally not important. The patients encountered little or no difficulty in theis day-to-day activities. Our modification of use of a wide mesh as inlay and onlay repair minimizes the donor site morbidity. This also avoids maneuvers meant for primary closure of the rectus sheath defects, which can result in distortion of umbilicus. Therefore, in conclusion, the unipedicled TRAM flap should be regarded as a valuable option in breast reconstruction provided careful repair of the abdominal wall defect is undertaken using Proline mesh.

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Introduction: An Internet-based group of plastic surgeons was formed in India in February 2001. It has 1290 members and seeks to facilitate online discussion. These discussions were reviewed to assess their value in education and aiding patient management. Materials and Methods: All messages and discussions between August 2007 and July 2008 were examined retrospectively. Data were collected regarding topics, replies, and use of clinical images. Results: A total of 2217 messages were exchanged within 330 separate discussions (mean = 6.7 messages per discussion, range = 0-45). A total of 164 discussions contained photographs (50%). Mean number of photographs per discussion was five (range = 0-34). Discussions included requests for advice on complex cases (40%), interesting cases and their management/outcome (25%) and courses/conferences (30%). Topics discussed include training/courses (26.7%), cleft (15.4%), aesthetics (13.1%), trauma (12.5%), head and neck (8.4%), cutaneous (6.4%), perineal/genital reconstruction (6.1%), and scar management (4.7%). Discussion: Forums like this facilitate discussion between individuals in remote locations. They provide easy access to the expertise of a large cohort of highly experienced surgeons. Most discussions were clinical, involving challenging situations. The discussions are open and nonjudgmental, hence encouraging contribution and healthy debate. We encourage its use as an educational tool and a platform for discussion.

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We present a case of carpal tunnel syndrome (CTS) due to compression of the median nerve within the carpal tunnel, caused by cysticercosis. Nerve conduction studies revealed severe CTS. Magnetic resonance imaging suggested an inflammatory mass compressing the median nerve in carpal tunnel. The histological diagnosis was consistent with cysticercosis. The case resolved with conservative treatment. Such solitary presentation of entrapment median neuropathy as CTS caused by cysticercosis is extremely rare. To our knowledge, this is the only case of its kind reported in literature till date.

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Tissue expansion though a promising modality of reconstructive surgery is fraught with many complications. In addition to expander-related complications, subcutaneous port-related mishaps during tissue expansion, though infrequent, can result in procedure failures. We are reporting two patients with port-related complications. In one patient, there was failure to localise the port and the other had a leaking port. Both the expanders were salvaged by retrieving the ports. In the former, as the port was competent, it was simply exteriorised. But in the later case, the connecting tube was retrieved and the incompetent port was replaced with a Luer lock external port. Both the cases were successfully salvaged without any further complications. Expansions were completed and requisite reconstructive end points were achieved.

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A case of a female child born at full term after normal vaginal delivery with bilateral secondary complete cleft palate and vomerine hamartoma mimicking intra-oral midline encephalocoele. Radiologically the tumour was confined to the vomer without intra-cranial extension. The lesion was occupying the oral cavity causing feeding problem. Surgical excision of the tumour at the age of six months and two flaps palatoplasty at the age of twelve months were performed. On histopathology the lesion turned out to be a lipomatous hamartoma of a benign nature. The child was followed for 9 years with no evidence of recurrence and a satisfactory speech. To our knowledge this is the first report of cleft palate with vomerine hamartoma in the English literature.

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Schwannoma is a relatively rare benign tumour of peripheral nerve origin. The occurrence of Schwannoma in eyelid is extremely rare. As per our knowledge, only 11 such cases have been reported in the literature so far. We present a case of a 40-year-old man who presented to us with a 2-year history of slowly enlarging, painless mass in his left upper lid with resultant progressive ptosis. Ocular examination was suggestive of a firm, non-tender nodule of size 2 Χ 1.5 Χ 1 cm on the left upper lid. The mass was non-adherent to the skin or the underlying tissue. The eyelid skin and conjunctiva were indurated and signs of inflammation were present. The lateral part of eyelid showed presence of an ulcer and the lid function was severely hampered. Provisional clinical diagnosis was that of an eyelid malignancy. With this in mind, the medial part of the lid was excised and reconstructed using a tarso-conjunctival flap from the lower eyelid in conjunction with a skin graft. The histopathology and immunohistochemistry established the diagnosis of Schwannoma. We recommend that Schwannoma be considered in the differential diagnosis of well-circumscribed eyelid swellings.

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