Pedicle First Anterior Approach to Harvest Anterolateral Thigh Flap-Review of 304 Cases.

Background Although considered as a workhorse flap, the anterolateral thigh (ALT) flap has a steep learning curve that makes it difficult for microsurgeons to perform it early in their practice. In over 85% of patients, the perforator takes an intramuscular course making it difficult for beginners to safely secure the perforator dissection. In this technique, the pedicle is dissected first, utilizing the proximal incision by palpating the groove in between vastus lateralis and rectus femoris on the anterior aspect and extending the incision from 2 to 3 cm distal to the inguinal ligament to the flap markings caudally. Exposing the pedicle first makes it easier to proceed toward the skin perforator due to its easy identification and larger size at its origin. Patients and Methods This retrospective study was conducted from 2005 to 2020 in which 304 ALT flaps were performed by the pedicle first technique. Flap harvest time, incidence of injury to the skin perforator during harvest, flap re-exploration rates, and postoperative complications including incidence of flap necrosis, infection, and bleeding were the parameters that were measured. Results This study included a total of 304 patients of which 220 were male (72.3%). The average flap harvest time was 26 ± 3.2 minutes. Adverse events included perforator injury ( n = 1), flap re-exploration ( n = 15), and complete flap loss ( n = 8). The last eight patients were reconstructed secondarily with ALT flap from the opposite side and free latissimus dorsi flap ( n = 2). Conclusion The pedicle first technique makes ALT flap harvest easy, safe, and faster for plastic surgeons. The chances of injury to the skin perforator are markedly less thereby reducing postoperative complications.

A comparative study of tissue expansion and free parascapular flaps in extensive facial burn scar reconstruction.

BACKGROUND: Large post burn scars are a very difficult problem to treat. Available methods include skin grafts and tissue expansion. The reconstructive method used should be tailored according to individual patient rather than following a textbook approach in each. PATIENTS AND METHODS: A retrospective analysis was done of cases with extensive facial burn scars in whom secondary reconstruction was done with either free parascapular flap cover or tissue expansion and flap advancement following facial burn scar excision by a single surgeon (GSK) in Department of Burns, Plastic and reconstructive surgery. RESULTS: A total of 15 patients with free parascapular flap and 15 patients with tissue expansion followed by flap advancement were analyzed in the group. There were no free flap failures, but 2 patients required skin graft at donor site. In patients undergoing tissue expansion, minor complication was noted in 1 patient. CONCLUSION: Tissue expansion is a useful technique in reconstruction of post burn scars, but has its limitations, especially in patients with extensive burns in head and neck region with limited local tissue availability. Parascapular free flap may provide a good alternative option for reconstruction in such cases.

Ovarian reserve may be compromised after adnexal surgery: Are we sufficiently fertility- focused in our surgical training?

There is a general trend towards delay in childbearing age amongst women. The ovarian reserve clearly falls with increasing age and the impact is greater with advancing age, particularly from late 30s. Presence of other risk factors can increase the risk of subfertility. A large number of women are exposed to pelvic surgery for various reasons, both elective and emergency. There is evidence that some of the pelvic surgery performed around ovaries and tubes has a negative impact on the ovarian reserve and in turn may cause a decline in woman's ability to conceive. A fertility-sparing focus on all pelvic surgery is likely to prevent further decline in ovarian reserve for women who are already at higher risk. Such focus seems to be currently lacking. It is proposed that integrating fertility-sparing focus to structured gynaecological surgical training will benefit women.

Posttraumatic intradiploic epidermoid cyst of frontal bone.

Intracranial epidermoid cysts constitute about 1% of all intracranial tumors. They are usually congenital in origin and are thought to derive from ectodermal cell inclusions occurring during closure of the neural tube. Twenty-five percent of these are found in the skull as intradiploic epidermoid cysts. These intradiploic cysts are usually congenital, slow growing, and can grow to large size without causing symptoms. We present a case of intradiploic epidermoid cyst of frontal bone developed due to childhood trauma. The cyst expanded and eroded the walls of the frontal sinus causing proptosis, diplopia, and restricted eye movements with frontal headache. The bicoronal flap approach was used for complete removal of the cyst. Complete removal of the cyst wall is necessary to avoid recurrence.

Temporomandibular joint ankylosis fixation technique with ultra thin silicon sheet.

BACKGROUND: Temporomandibular joint ankylosis is a highly distressing condition in which the joint space is obliterated by scar tissue and the patient has an inability to open the mouth. Different autogenous and alloplastic interposition materials have been used after the resection of the ankylotic bone to achieve desirable and long lasting results. The recurrence of disease is most distressing for both patients and surgeon. We have been using ultra thin silicon sheet as our preferred material for providing proper fixation and cover to the joint. We have been encouraged by good patient compliance, no implant extrusion and favourable outcome. MATERIALS AND METHODS: The clinical study included 80 patients with temporomandibular joint ankylosis, treated between April 2001 and March 2009. In all patients, temporomandibular joint ankylosis had resulted following trauma. Diagnosis was based on clinical assessment supplemented by radiographic examination consisting of a panoramic radiograph, axial and coronal computer tomography. The technique of using ultra thin silicon sheet covering whole of the joint space fixed with non-absorbable nylon 3-0 suture both medially to medial pterygoid muscle and laterally to periosteum of zygomatic arch was employed in all patients. RESULTS: A total of 80 patients were in this study (59 males and 21 females). The aetiology of temporomandibular joint ankylosis was post-traumatic in all cases. The patients' age ranged from 5 to 45 years. The disease was unilateral in 61 cases and bilateral in 19 cases. Twelve patients, who had previous surgery done in the form of gap arthroplasty in 6 cases, costochondral graft in 4 cases and temporalis muscle in 2 cases, presented with recurrence on the same side. The pre-op inter-incisal mouth opening ranged from 4 to 12 mm. The intraoperative inter-incisal mouth opening ranged from 28 to 46 mm. An additional procedure was done in 13 patients, including placement of costochondral graft with coronoidectomy in 4 of these cases. There was no immediate complication and no incidence of facial nerve injury. There was no extrusion of the implant in immediate and follow-up period. CONCLUSIONS: The use of alloplastic implants with less volume and proper fixation covering all the raw bone joint space prevents reunion of bone; fixation of the sheet prevents its movement and thus extrusion.

Transcatheter closure of ruptured sinus of valsalva aneurysm.

Percutaneous transcatheter closure of ruptured sinus of valsalva aneurysm was attempted in eight patients between January 1995 and March 2003 as an alternative strategy to surgery as this technique at present is an accepted therapeutic modality for various intracardiac defects. The age range was 14-35 years, all were male, seven in symptomatic class III and one in class IV on medical treatment. Two-dimensional and color Doppler echocardiography revealed rupture of an aneurysm of right coronary sinus into right ventricle in five and noncoronary sinus into right atrium in three and none had associated ventricular septal defect. The echo estimated size of the defect was 7-12 mm. On cardiac catheterization left ventricular end-diastolic pressure ranged from 20 to 40 mmHg and the calculated Qp/Qs ratio was 2-3.5. In all patients the defect was crossed retrogradely from the aortic side and over an arterio-venous wire loop after balloon sizing, devices were successfully deployed by antegrade venous approach (Rashkind umbrella device in two and Amplatzer occluders in six, which included Amplatzer duct occluder in five and Amplatzer septal occluder in one). One patient who had residual shunt developed hemolysis on the next day and was taken up for reintervention. That patient continued to have intermittent hemolysis and was sent for surgical repair. On follow-up (2-96 months), there was no device embolization, infective endocarditis, and aortic regurgitation. One patient died of progressive congestive heart failure while other six are asymptomatic. These data highlight that transcatheter closure is feasible and effective, especially safe with the available Amplatzer devices. Definitely, it has the advantage of obviating open heart surgery but complete occlusion is mandatory to prevent hemolysis and infective endocarditis.

Transcatheter closure of congenital ventricular septal defects: experience with various devices.

Transcatheter closure of congenital ventricular septal defect (VSD) using various devices is gaining acceptance in selected cases of perimembranous and muscular defects, avoiding the inherent risks of cardiopulmonary bypass. The procedure was attempted in 137 patients having congenital defects using Rashkind Umbrella Device (RUD) in 29 patients, Amplatzer ventricular septal occluder (AVSO) in 107 patients, and Detachable Coil in one. All patients were selected using stringent criteria by detailed transthoracic echocardiography and/or transesophageal echocardiography. The location of VSD was perimembranous in 91 patients and was muscular trabecular in 46 patients. Seven patients had left ventricle (LV) to right atrium (RA) communication. Thirty-five patients with perimembranous and two with muscular VSD had aneurysm formation. The patients were 3 to 33 years old, and the diameter of VSD ranged from 3 to 12 mm. The pulmonary to systemic flow ratio was > or = 2:1 in 47 (34.3%) patients. The procedure was successful in 130 (94.8%) patients, with a success rate of 86.2% with RUD and 97.1% with AVSO. Residual shunt at 24 hours was seen in eight (32%) patients with RUD and in one patient (0.9%) with AVSO. Three (2.8%) developed transient bundle branch block, and two (1.9%) patients had complete heart block. New tricuspid stenosis and tricuspid regurgitation was observed in one patient each with AVSO. After immediate balloon dilatation, the mean pressure gradient across tricuspid valve decreased from 11 to 3 mmHg in the patient with tricuspid stenosis. On a follow-up of 1 to 66 (mean 35.2 +/- 10.7) months, the device was in position in all. None developed late conduction defect, aortic regurgitation, infective endocarditis, or hemolysis. At 9-month follow-up, the mean pressure gradient across the tricuspid valve was 3 mmHg in the patient with tricuspid stenosis. Complete occlusion of the shunt was achieved in 129(99.2%) patients. One patient with RUD having persistent residual shunt underwent a second procedure with AVSO. Three out of 107 patients with AVSO had an unsuccessful procedure where the defect was perimembranous with a superior margin of defect less than 3 mm away from the aortic valve, and the specially designed perimembranous AVSO had to be retrieved because of hemodynamic compromise due to significant acute aortic regurgitation, whereas in all others, the defect was either > or = 3 mm away from the aortic valve or had aneurysm formation. All seven patients with LV to RA communication showed complete abolition of the shunt. Thus, in properly selected cases of perimembranous and muscular ventricular septal defects, the transcatheter closure is safe and efficacious using appropriate devices. The success rate is higher with AVSO compared with the previously used devices, as well as more successful for the muscular defects than those that are perimembranous in location.

Initial human experience with the Amplatzer perimembranous ventricular septal occluder device.

Transcatheter closure of perimembranous ventricular septal defects with coils or devices designed to close other lesions may be complicated by embolization or aortic insufficiency. A new asymmetric Amplatzer perimembranous ventricular septal occluder and delivery system was specifically designed for perimembranous defects. This report describes the first use of this device in 27 patients. Implantation was successful in 25 (93%), with 1 removed for device-related aortic insufficiency and inability to position the delivery sheath in another. Device orientation was excellent when the device was initially advanced through a standard delivery sheath positioned in the left ventricular apex. Twenty-three had complete occlusion within 1 week (92%), with a tiny (< 2 mm) residual shunt in the other two. In the 25 subjects with the device left in place, device-related aortic or tricuspid insufficiency, arrhythmias, and embolization were not observed. These excellent acute results need to be confirmed by long-term follow-up.

Proboscis lateralis of nose.

A rare case of congenital malformation of the nose that was successfully corrected surgically is reported.

Dermatofibrosarcoma protuberans of scalp : a case report.

A case of dermatofibrosarcoma protuberans of scalp involving the underlying bone, operated after recurrence by taking safety margin of 3 cm and skin deficit covered by transposition flap, is being reported. Modality of treatment has been discussed.

Mitral regurgitation following percutaneous transvenous mitral commissurotomy: a single-center experience.

BACKGROUND AND AIM OF THE STUDY: Percutaneous transvenous mitral commissurotomy (PTMC) has revolutionized the treatment of patients with symptomatic mitral stenosis and is now established as the procedure of choice. Despite high technical expertise in PTMC using the Inoue balloon, mitral regurgitation (MR) remains a major procedure-related complication. We retrospectively analyzed our data of PTMC using the Inoue balloon with regard to the incidence of MR, its likely causative mechanism, and follow up of these patients. METHODS: During the past ten years, PTMC was performed in 3,650 patients (median age 26 years; range: 8-76 years), of whom 910 (24.9%) were juveniles. Preprocedure mitral valve area (MVA) was 0.9 +/- 0.4 cm2 (range: 0.3-1.3 cm2); MR was mild in 1,396 cases (38.2%), moderate in 394 (10.8%) and severe in 22 (0.6%). None of the patients was rejected on the basis of echocardiographic score. RESULTS: The procedure was successful in 3,276 (89.8%), with post-procedure MVA of 1.7 +/- 0.6 cm2 (range: 1.4-2.6 cm2), and without development of any major complication. Severe MR was seen in 120 patients (3.3%), of whom 66 (1.8%) required urgent mitral valve replacement (MVR). Echocardiography in these latter patients showed leaflet rupture in 48 (72.7%), chordal rupture in 12 (18.2%) and excessive commissural tear in six (9.1%). Fifty-four patients (1.5%) with severe MR post PTMC were followed with medical treatment; echocardiography in these patients revealed chordal rupture in 40 (74.1%) and excessive commissural tear in 14 (25.9%). Follow up data were available in 49 patients (1.3%); 30 (0.8%) required MVR and 19 (0.5%) were in NYHA class II at a median follow up of 24 months. Moderate MR was seen in 188 cases (5.1%), with predominant causative mechanisms of excessive commissural tear in 120 (63.8%) and chordal rupture in 68 (36.2%). Severity of MR worsened in 30 cases (0.8%), of which 20 (0.6%) required elective MVR on follow up. MR decreased in 58 patients (1.6%), in whom excessive commissural tear was the causative mechanism. CONCLUSION: Significant MR (moderate or severe) after PTMC was seen in 308 patients (8.4%), of whom 116 (3.2%) required MVR urgently or on follow up. All patients with leaflet rupture during PTMC developed severe MR and required urgent MVR. There was a tendency for the severity of MR to decrease with time in cases where excessive commissural tear was the causative mechanism.

Transcatheter closure of ventricular septal defect using detachable steel coil.

Transcatheter closure has been attempted in selected cases of ventricular septal defects using Lock clamshell device, Rashkind umbrella device, and Sideris buttoned device. A small perimembranous ventricular septal defect with aneurysm of membranous septum in a 12 year old girl was closed successfully with a detachable steel coil of 8 mm diameter with four loops, after failure of deployment of a Rashkind double umbrella device.

Transcatheter device closure of ventricular septal defects: immediate results and intermediate-term follow-up.

BACKGROUND: Transcatheter closure is an accepted mode of treatment in selected cases of congenital heart disease. Lately, this technology has been applied to closure of ventricular septal defect (VSD). METHODS AND RESULTS: We performed percutaneous transcatheter closure of VSD in 30 patients. The location of VSD was perimembranous in 28 patients and muscular trabecular in 2. Two (7%) patients also had left ventricular-right atrial communication. There were 17 male subjects and 13 female subjects, with an age range of 5. 5 to 33 years (mean +/- SD, 12.9 +/- 5.7; median 12.2). The diameter of VSD ranged from 3 to 8 mm (mean +/- SD 4.7 +/- 1.3; median 4.5). In 5 (17%) patients, the pulmonary to systemic blood flow (Qp/Qs) was >/=2.1 (range 2.0 to 2.6). The defect was at least 6 or 8 mm from the aortic valve in patients in whom a 12- or 17-mm Rashkind double umbrella device was deployed, respectively. In 1 patient, the defect was closed with a detachable stainless steel coil, size 8 mm, with 4 loops (8 x 4). The devices were successfully deployed in 87% of patients. In 6 (20%) patients, the procedure had to be repeated primarily because of the use of undersized umbrella deices. Unsuccessful deployment of the device occurred in 4 (13%) patients. In one of these procedures, the coil embolized to the left pulmonary artery, and it was successfully retrieved. A minimal residual shunt seen as a thin streak on transthoracic color flow mapping persisted in 8 (30%) patients, which remained unchanged over a follow-up period of 5 to 28 (17.1 +/- 6.4) months. Both patients with left ventricular/right atrial communication showed complete abolition of the shunt. No patient developed new-onset aortic or tricuspid regurgitation or intravascular hemolysis. At follow-up, no patient had developed infective endocarditis, bundle branch block, or late valvular insufficiency. CONCLUSIONS: Transcatheter closure is safe and efficacious in selected cases of perimembranous and muscular VSD.

Transcatheter closure of atrial septal defect using self-expandable septal occluder.

Transcatheter closure of atrial septal defect is an accepted alternative to surgical closure. It was attempted in 63 patients (age range 1.5-55 years) using self-expandable Amplatzer septal occluder (AGA Med. Co., USA). The atrial septal anatomy was evaluated by transthoracic and multiplane transoesophageal echocardiography with special reference to septal margins and adjacent structures. The size of atrial septal defect on echocardiographic evaluation varied from 9-28 (17.5 +/- 4.7) mm. Fifty (79.4%) patients had adequate septal margins of 5 mm or larger, while remaining 13 (20.6%) had insufficient anterosuperior margin. Cardiac catheterisation revealed Qp/Qs ranging from 1.5 to 5.3 and balloon-stretched atrial septal defect diameter of 10-32 (20.3 +/- 5.3) mm. The procedure was overall successful in 62 (98.4%) patients and in all patients with insufficient anterosuperior margin. Embolisation of the device occurred in one (1.6%) patient within five minutes of the device release, which could not be retrieved non-surgically. Size of the device used was either same or preferably 1-3 mm more than the balloon-stretched atrial septal defect diameter. Total procedure time was 40-90 (59 +/- 12.4) minutes and the fluoroscopy time was 12-30 (17.3 +/- 4.2) minutes. Immediate post-procedure and pre-discharge echocardiography in patients with successful deployment of the device revealed complete abolition of shunt in 61 (98.4%) and trivial residual shunt in one (1.6%) patient. No patient developed atrioventricular valve regurgitation or cardiac arrhythmias. Thus, atrial septal defect closure using self-expandable septal occluder is a safe and efficacious procedure requiring a short procedural time. There is full control in the system for proper positioning or repositioning of the device with excellent technical success rate even in cases with insufficient anterosuperior septal margin.

Transcatheter closure of secundum atrial septal defect with atrial septal defect occlusion system (ASDOS): initial experience and short-term follow-up.

Transcatheter closure of secundum atrial septal defect is a well known alternative to surgery. It was attempted in seven patients (age range 7-34 years, mean 20.1 +/- 6.5 years) with the double umbrella nitinol device (ASDOS, Dr. Ing Osypka, Germany). The interatrial septal anatomy and blood flow were examined by transthoracic and multiplane transoesophageal echocardiography. The size of atrial septal defect varied from 1.25-2.4 cm (mean 1.75 +/- 0.3 cm), minimal septal rim 0.5-1.0 cm (mean 0.75 +/- 0.20 cm), and Qp/Qs 1.6-3.2:1 (mean 2.4 +/- 0.6). One patient had an atrial septal defect following surgery for left atrial myxoma. The procedure which involved the use of monorail system for deployment of device under transoesophageal echocardiography guidance, was successful in six (86%) of the seven patients. The size of the implanted device ranged from 30-45 mm. In two patients, the right atrial umbrella had to be oversized in comparison to the left atrial umbrella for stability and adequate occlusion of the defect. The patient in whom the procedure failed had a defect size of 1.7 cm, with minimal septal rim (anterosuperior) of 5 mm; however, the device could be easily retrieved. Immediately after and at follow-up of one year, transoesophageal echocardiography-guided colour flow mapping revealed complete abolition of left-to-right shunt in five (83%) of the six patients. One patient had a small residual flow at the posterior rim of the defect; none had atrioventricular valve regurgitation. Although the procedure is complex, it is safe with the advantage of excellent control on the monorail system for proper positioning, repositioning and, if required, retrieval of the device.

Non-surgical mitral commissurotomy using metallic commissurotome.

Percutaneous transatrial mitral commissurotomy using a new miniaturised metallic commissurotome mounted on a 12 F catheter was done in 24 patients with severe mitral stenosis. There were 17 (70.8%) females and seven (29.2%) males with age ranging from 12-42 years (mean 26.0 +/- 6.7 years). Atrial fibrillation was present in three (12.5%) patients. Three (12.5%) patients had restenosis following closed mitral commissurotomy. The mitral valve score on echocardiography ranged from 6 to 10 (mean 7 +/- 1.3). The procedure was performed with one device which was reused after sterilisation with glutaraldehyde. The device was opened maximally upto 39.0 +/- 1.7 mm (range 35-40 mm). The procedure was successful in 23 (95.8%) patients. The mean left atrial pressure decreased from 26.8 +/- 8.0 to 9.3 +/- 7.1 mm Hg (p < 0.001). There was a fall of mean pulmonary artery pressure from 47.2 +/- 18.6 (range 20-29 mm Hg) to 23.6 +/- 9.6 mm Hg (range 12-51 mm Hg) (p < 0.001). The mitral valve area as assessed by Doppler echocardiography (pressure half time) increased from 0.9 +/- 0.1 (range 0.6-1.2 cm2) to 2.1 +/- 0.4 cm2 (range 1.6-2.6 cm2) (p < 0.001), with split in both commissures in 22 (95.6%) cases. One patient developed severe mitral regurgitation with tear in the anterior mitral leaflet needing immediate mitral valve replacement. One patient developed transient aphasia which recovered completely within four hours. Percutaneous transatrial mitral commissurotomy using metallic commissurotome offers reliable and effective alternative to balloon mitral commissurotomy and may be more cost-effective because of its reusability.

Transcatheter coil occlusion of persistent ductus arteriosus using detachable steel coils: short-term results.

Twenty patients underwent transcatheter occlusion of persistent ductus arteriosus (PDA), 1.5-5.5 mm in diameter, with detachable steel coils. A coil having a diameter at least twice that of the narrowest ductal diameter was used. Procedural success was achieved in all, using a single coil in 14 and multiple coils in the remaining 6. At follow-up after 2-12 (6.7 +/- 2.8) months, continuous murmur persisted in only one patient, while 4 (20%) patients had residual shunt on Doppler colour-flow imaging. There was no instance of coil embolisation, thromboembolism, intravascular haemolysis, local vascular complication or sepsis. Transcatheter occlusion of PDA with detachable coils is a safe, technically easy and cost-effective method with the added advantage of feasibility in small children.

Ameloblastic sarcoma with diverse mesenchymal differentiation.

This report describes a rare case of ameloblastic sarcoma involving right maxilla, with unusual ocular involvement. Diverse mesenchymal differentiation towards fibrohistiocytic, fibrosarcomatous and malignant osteoid component along with dysplastic dentine observed in the tumour is being reported for the first time.

Persistent buccopharyngeal membrane: a report of two cases.

Persistent buccopharyngeal membrane is an extremely rare clinical entity that can be diagnosed easily by simple examination of the oral cavity and confirmed by a lateral contrast x-ray. The abnormality can be easily corrected surgically.