Giant Penoscrotal Lymphedema: Planning And Surgical Technique To Treat A Rare Debilitating Disease.

BACKGROUND: Giant penoscrotal lymphedema is a rare condition and is treated by surgical debulking and reconstruction with remaining skin and skin grafts. The described techniques may result in a staged surgery, multiple blood transfusions, orchidectomy and early debulking of the scrotal skin. We present a case series describing our technique to address all the concerns, discuss management to decrease progression and transmission in secondary cases and present a novel questionnaire to assess of quality of life of these patients. METHODS: This descriptive case series was done from July 2016 to October 2019. Patients with Campisi grade 5 disease were included. Clinical assessment and relevant investigations were done to identify the cause and confirm the extent of the disease. Procedural detail, post-op haemoglobin levels (Hb), need for transfusion and weight of excised specimen were recorded. Wound healing, recurrence and body mass index were noted on follow up. A scrotal lymphedema quality questionnaire was developed and was filled on follow-up visit. RESULTS: Twelve patients were operated on. The mean history was 3.0±0.5 years. 4 tested positive for microfilariae, while 4 out of 8 who tested negative had taken the anthelmintic drug. The mean weight excised was 15.8±2.3 kg, mean pre-operative score on quality-of-life assessment questionnaire was 83.3±2.6 versus 9.3±0.8 post operatively. The mean follow up time was 1.4±0.6 years. 1 patient had a minor recurrence necessitating re excision. Mean Hb was 13.5±0.5 mg/dl preoperatively compared to 11.8±0.5 mg/dl post operatively, with none requiring transfusion. CONCLUSIONS: Single staged excision with split thickness skin grafting is an effective and safe way to treat patients with giant scrotal lymphedema. It's the single best way to address the quality of life of patients.

Application Of Cling Film Over Burn Wounds (Occlusive Wound Dressing): Our Experience.

BACKGROUND: This study shares our experience and review the outcome of the use of cling film with silver sulfadiazine cream in terms of healing time, and patient's satisfaction score. METHODS: It was a descriptive case series conducted at Jinnah Burn and Reconstructive Surgery Center, Lahore, from March 2018 to February 2019. In this study, a thick layer of silver sulfadiazine was applied and then wrapped with cling film on 35 patients sustained mix thickness burns on the trunk and limbs. Dressing was done daily after wound wash with normal saline. Consultant Plastic surgeon assessed the wound healing by observation and serial photographs. Duration of wound healing and complications were noted. RESULTS: Complete wound healing was achieved in 25 (71.4%) patients with mean healing time of 13.3 days (range 11-15 days). The wound infection was seen in 5 (14.2%) patients, that were diagnosed by change in colour of wound edges and patients with signs of sepsis (ABA scoring). Sepsis was treated in 5 patients with debridement and culture specific antibiotics. split skin graft done in 8 (22.8%) cases. CONCLUSIONS: Moist wound dressing with Silver Sulfadiazine and cling film is cost effective, easy to apply with good visibility of the wound and has good patient satisfaction, but is labour intensive.

Glycerol Preserved Amnion: A Viable Source of Biological Dressing for Superficial Partial Thickness Facial Burns.

OBJECTIVES: To evaluate the role of amnion as a biological dressing in superficial partial thickness facial burns. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Jinnah Burn and Reconstructive Surgery Centre, Lahore, from January 2017 to December 2018. METHODS: Sixty two patients with superficial partial thickness facial burns were randomly divided into two groups (A and B). Ointment containing Polymyxin B and Bacitracin was applied in group A (n=28) while amnion was applied in group B (n=34). The patients were monitored for the pain related to burns needing analgesia, time of healing of burns, and cosmetic outcome of the facial scarring over a period of six months. RESULTS: The mean age of the patients was 26.5 ±12.2 years. 39 (62.9%) patients were male and 23 (37.1%) were females. The mean percent total facial surface area burned was 2.7% ±1. None of the patients developed facial wound infections. The average healing time was 6 ±2 days. The mean frequency of analgesia for 3 days of group B was less as compared to group A. infection rate was similar in both groups. No significant difference was observed in VAS score at 1, 3 and 6 month follow up between both groups. CONCLUSION: Amnion is a safe, cost effective and most readily available biological dressing for superficial partial thickness facial burn management. Key Words: Amnion, Facial burn, Biological dressing, Scarring, Partial thickness burn.

Accuracy of Thermal Imaging Camera in Identification of Perforators.

OBJECTIVE: To determine the diagnostic accuracy of thermal imaging camera in the identification of perforators using peroperative visual inspection as gold standard. STUDY DESIGN: Descriptive study. Place of Study: Jinnah Burn and Reconstructive Surgery Centre / Allama Iqbal Medical College, Lahore, from October 2017 to September 2018. METHODOLOGY: Patients undergoing pedicled or free perforator flap for reconstructive surgery of upper and lower limb, abdomen, groin, and head and neck region, where soft tissue defect was caused by trauma (road traffic accidents and electric burns), were included in this study. All patients underwent the same treatment protocol of identification of perforator location with Flir One camera preoperatively. Later, it was confirmed peroperatively by visual inspection. Diagnostic accuracy was calculated in terms of sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Diagnostic accuracy in identification of perforators in pedicled (n=154) and free flaps (n=30) by thermal imaging camera was calculated as sensitivity of 86.2%, specificity of 80.0% with the positive and negative predictive values of 98.7%, and 25.0%, respectively. CONCLUSION: Flir One, a smartphone-compatible miniature thermal imaging camera, is useful for the detection of perforators and is highly sensitive and specific. Key Words:  Flir One, Perforators, Thermal imaging, Thermal imaging camera.

Antioxidant pretreatment enhances umbilical cord derived stem cells survival in response to thermal stress in vitro.

Aim: Pretreatment of stem cells with antioxidants accelerates their ability to counter oxidative stress and is associated with the overall therapeutic outcome of their transplantation. Material & methods: Wharton Jelly derived mesenchymal stem cells (WJMSCs) were cultured and pretreated with various doses of antioxidants; Vitamin C (Vit C), Vitamin E (Vit E), Vitamin D3 (Vit D3) and their Cocktail, followed by exposure to in vitro heat injury. Assessment of WJMSCs survival, paracrine release, in vitro wound healing and expression of angiogenic and survival markers was conducted. Results: The results displayed an enhanced survival of WJMSCs especially in the case of Cocktail priming. Conclusion: Our data suggest that antioxidant pretreatment of WJMSCs strengthens the endurance of the cells, within stress conditions.

Vacuum-assisted Closure in Integration of Skin Graft Over Scalp Wounds: A Randomised Control Trial.

OBJECTIVE: To compare outcome of split thickness graft with and without vacuum-assisted closure over the scalp soft tissue defects in terms of graft take and complications. STUDY DESIGN: Randomised controlled trial. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, Jinnah Burns and Reconstructive Surgery Centre, Lahore, from June 2017 to June 2018. METHODOLOGY: Patients with scalp soft tissue defects were recruited for the study. Patients with history of poly trauma, hypertension and diabetes mellitus were excluded. Patients were randomly divided into two groups by balloting lottery method. In group A, simple dressing were done after split thickness skin graft; and into group B, VAC dressing was applied after split thickness skin graft. Outcome variables (graft take and complications rate at recipient site) were assessed clinically at 2 weeks and analysed by Chi-square test with p-value <0.05 was taken as significant. RESULTS: Mean age of 120 patients was 33.44 ±14.65 years. Graft take was seen in 24 (40.0%) patients in group A and in 56 (93.3%) patients in group B (p = 0.0001). Seroma was recorded in eight (13.3%) in group A (simple dressing) patients and one patient (1.67%) in group B (VAC dressing, p = 0.015), hematoma was seen in 04 (6.67%) versus 0 (0.0%), respectively (p = 0.042) and graft edge dehiscence in 03 (5.0%) versus 0 (0.0%), respectively (p = 0.079). CONCLUSION: Outcome of split skin graft over scalp soft tissue defects with VAC dressing is better than simple dressing in terms of graft take and complications rate.

Lower extremity reconstruction: utility of smartphone thermal imaging camera in planning perforator based pedicled flaps.

BACKGROUND: Presence of good size perforators are mandatory to design perforator based pedicelledflaps specially in lower limb as flap failure rate isrelativelyhigh. We have explored the use ofsmartphonebaseddynamic thermal imagingand compared it with doppler to devise a protocol forplanning and executionof pedicled perforator flaps anddescribedits use in deciding delay of flap. We have also compared the time required for detecting dominant perforators. METHODS: This prospective case series was done atJinnah burn and reconstructive surgery center Lahore from July to September 2018and included patients requiring pedicled fasciocutaneous or musculocutaneous flapfor lower extremity reconstruction. Smartphonebased dynamic thermal imaging and doppler wereused to map out suitable perforators and confirmed intraoperatively. Comparison was made regarding their ability to locatedominant perforatorsandtotal time required.Utility of thermal imaging to ascertain flap perfusion postoperatively was also assessed.Flaps were designed according to thermal mapping. Clinical judgement supplemented with thermal imaging was usedto ascertain flap survival. RESULTS: The study included 15 patientsin which22 out 23 dominant perforators as located withthermal imaging were confirmed intra-operatively (positive predictive value = 95.7%) as compared to 22 out of 32 with doppler(positive predictive value=68.8%). Mean time required with doppler was 591.27±252.48, compared to 598.47±192.94 seconds with thermal imaging. In two cases flap was delayed. Partial flap necrosis occurred in one case. CONCLUSION: Dynamic thermal imaging can be reliably usedin planning of pedicled perforator flaps for lower limb reconstruction. We have found itmore reliable than handhelddoppler in locating dominant perforators.

Deep-seated Hibernoma of Thigh: A Rare Benign Adipocytic Tumor.

Hibernoma is a rare benign soft tissue adipocytic tumor. Mostly found in adults, it is usually located in the limbs, and is deepseated or intramuscular. Usually asymptomatic, it causes symptoms when it becomes large enough to compress adjacent structures, mimicking well differentiated liposarcoma clinically and radiologically. We present a case report of a deepseated hibernoma of thigh. Radiological investigation and incisional biopsy were done to diagnose and define the surgical roadmap to completely excise it. We describe our technique to precisely control feeding vessels and meticulous dissection to preserve thigh muscles to retain function.

Early Active Mobilization Vs Immobilization Following Modified Kessler Repair Of Extrinsic Extensor Tendons In Zone V TO VII.

BACKGROUND: The long-disputed issue of rehabilitation of extensor tendon repairs in zones V-VII has been treated with either complete immobilization or mobilization within the constraints of splint. In recent times, most authors have preferred some mobilization. Many studies have shown good results with early mobilization techniques; however, these studies have limitations. Most of these are retrospective observations. Some prospective studies are without proper controls. This study was conductive to compare the functional outcome of early active mobilization versus immobilization following repair of extensor tendons in zone V-VII. METHODS: Functional outcome was determined by total active motion, pain and complications during rehabilitation. Total active motion (TAM) was graded by scores of the American Society for Surgery of Hand as TAM=total active flexion (MCP+PIP+DIP)-total extension deficit (MCP+PIP+DIP). A randomized control trial was conducted including 50 subjects of with extensor tendon injury exclusively in zone V-VII. Patients were divided randomly in two groups. All extensor tendon repairs (zone V to VII) were performed with modified Kessler's method. The pain and TAM was assessed during all visits in both groups except TAM in group B that was assessed after four weeks. RESULTS: We found that outcome of 12% cases in Group A as excellent and no patient fell in category of fair results. While, in comparison, there was no case of excellent result in Group B. 4% cases showed fair results that were treated with immobilization. The pain score at the end of treatment, i.e., at 12 weeks were same in both the groups but, generally the score remained higher in group of EAM. There was significant difference in adhesion formation that was more in patients of immobilization group. The overall suture dehiscence was insignificant and was only 8% in each group. CONCLUSIONS: EAM has better outcome in terms of pain and range of motion.

Efficacy Of Micro-Needling On Post Acne Scars.

BACKGROUND: Acne effects 80-90% of teenage population all around the world. Resulting scars can lead to facial disfigurement and psychological issues in affected population. To counter this problem many treatment options have been tried including resurfacing lasers, dermabrasion, peeling, fillers, platelet rich plasma therapy etc. All have shown variable results. Among these modalities, micro needling is showing promising results in treatment of acne scars due to collagen induction. This study was conducted to assess efficacy and safety of micro-needling on acne scars. METHODS: In this cross-sectional study a total of 50 patients (female 35, male 15) underwent treatment for post acne scarring, 4 sessions of micro-needling were done under local anaesthesia 3 weeks apart over the span of 2 months. Initial and follow up qualitative assessment was done. Photographs were taken of each patient on their subsequent visit, they were analysed and compared for final results. Grading was done by using Goodman Baron scale. RESULTS: 70% (35) were females and 30% (15) were males with mean age of 27.31±4.41 ranging from 19-35 years. After the treatment of scars, 73% (08) of Grade 4 scars have showed improvement by 2 grades, remaining 27% (03) showed improvement to Grade 3. In 20 patients with Grade 3 scars, 30% (06) showed improvement by 1 grade. Remaining 70% (14) improved by 2 grades. All patients with Grade 2 scar downgraded to grade 1 after treatment. Chi-square test was used to assess pre-treatment and post treatment grading improvement among subjects and was statistically significant. (X2=30.010 p=000).. CONCLUSIONS: Micro needling is an effective tool for aesthetic improvement of post acne scarring.

Granulocyte Colony Stimulating Factor in Burn Patients with Neutropenia.

OBJECTIVE: To assess the role of granulocyte-colony stimulating factor (G-CSF) for improving neutropenia in burns patients with neutropenia. STUDY DESIGN: Experimental study. PLACE AND DURATION OF STUDY: Jinnah Burn and Reconstructive Surgery Centre, Lahore, from May to October 2017. METHODOLOGY: Patients with burn injury, having absolute neutrophil count (ANC) <500 / µL or where it was expected to decrease to <500/µL within the next 48 hours, were recruited in the study. A detailed demographic profile of patients was taken, burn site was evaluated, and sample collection by phlebotomy was done in the complete blood count (CBC) vial. Samples were run in a CBC analyser and verification of neutrophil count on the neubuar chamber was done. ANC was taken for 3 days for each patient. Injection Filgrastim was given 300 µg subcutaneous (S/C) or intravenous (I/V) once daily until the neutropenia improved. Improvement was categorised as good, moderate and poor, depending on the number of days for improvement in ANC. The response was further stratified on the basis of age, gender and percentage of burn. RESULTS: A total of 39 patients with mean age of 32.1±14.4 years included 84.6% (n=33) males and 15.4% (n=6) females. Mean percentage of burn was 40.5±15.7%. In 12-40 years of age, there were 30/39 (76.9%) patients. Among them, 11/30 (36.6%) were good, 13/30 (43.3%) were moderate, and 6/30 (20%) were poor responders. In 41-70 years of age, there were 9/39 (23.1%) patients. Among them, 2/9 (22.2%) were good, 4/9 (44.44%) were moderate, and 3/9 (33.3%) were poor responders (p = 0.616). CONCLUSION: The addition of G-CSF injections to the standard treatment of burn injury markedly improve the neutrophil counts in burn patients with neutropenia.

Complex Reconstruction of Nose and Upper Lip after Assault.

A 21-year male, farmer by profession, was admitted in Plastic Surgery Department via outpatient department, with amputation of nose and upper lip with the knife during resistance against robbery attempt. He was having the blockage of the right side of nostril and difficulty in mouth opening. Upper lip vermilion and mucosal reconstruction with the bilateral facial artery musculo-mucosal (FAMM) flap and moustache reconstruction was done with visor flap. Split thickness skin graft (STSG) was done over the donor site. Division and insetting of visor flap was done after two weeks. After three months, all three nasal layers were reconstructed. The inner lining was reconstructed with the turn down flap, L-strut from rib cartilage, and the outer lining with forehead flap.

Oropharyngeal, Hypopharyngeal and Cervical Esophageal Reconstruction: An Experience of Pedicle Flaps.

OBJECTIVE: To review the experience of single-stage reconstruction following pharygolaryngectomy and cervical esophageal defect with pedicle flaps in a tertiary care centre. STUDY DESIGN: Retrospective study. PLACE AND DURATION OF STUDY: Jinnah Burn and Reconstructive Surgery Centre, Lahore, from June 2007 to June 2017. METHODOLOGY: All patients who underwent oropharyngeal, hypopharyngeal and cervical esophageal reconstruction with pedicled flaps were included. RESULTS: Thirty-two reconstructions were done, of which 16 (50.0%) were supraclavicular flaps, 12 (37.5%) were pectoralis major myocutaneous flaps (PMMF) and 4 (12.5%) platysma myocutaneous flaps (PMF). Among these, 24 (75%) were males and 8 (25%) females. The mean hospital stay was 18.75 +5.45 days. Complications were noted in 12 (37.5%), salivary fistula being the most frequent found in 6 (18.75%). Wound dehiscence was noted in 4 (12.5%), partial flap necrosis and wound infection present in 1 (3.1%) each. CONCLUSION: Oropharyngeal, hypopharyngeal and cervical esophageal reconstruction with pedicle flaps is still very useful and safe to perform, associated with minimal flap and donor site complications.

Comparison of efficacy and safety of intralesional triamcinolone and combination of triamcinolone with 5-fluorouracil in the treatment of keloids and hypertrophic scars: Randomised control trial.

The treatment of keloid and hypertrophic scar is challenging with no universally accepted mode for permanent ablation. Conventional therapies yield unpredictable results, significant complications and require elaborate hardware. OBJECTIVE: The objective was to establish the safety and efficacy of intralesional 5-fluorouracil (5-FU) for the treatment of keloids and hypertrophic scars. STUDY DESIGN: Randomized controlled trial (RCT). PLACE AND DURATION: It was conducted at the Jinnah Burn and Reconstructive Surgery Center/Allama Iqbal Medical College, Lahore, Pakistan from May 2012 to March 2013. SUBJECTS AND METHODS: We included 120 patients divided in two groups. The group A patients received intralesional triamcinolone acetonide (TAC) and the group B patients received both 5-FU and TAC. 8 injections at a week interval were given and patients were evaluated at the start of treatment and then at 4th and at 8th week during the treatment and then 4 weeks after the end of treatment. Patents were assessed for mean reduction in scar height, efficacy and complications. RESULTS: Total of 108 patients completed the study. The mean reduction in the scar height in group B (5-FU+TAC) 1.144+.4717 was markedly better than that of group A (TAC alone) 1.894+1.0751 (t=4.781, p=.000). The efficacy (defined previously as >50% reduction in initial scar height) was superior in group B 44 (77.2%) than that of group A 25 (49.0% (X2=9.260, p=.002). Recurrence was seen in 39.2% (20) of patients of the group A while in only 17.5% (10) of the cases of group B (P=0.012). Mean follow up was of 22 months. CONCLUSION: 5-FU+TAC is safe, easy to administer and effective treatment for problematic scars and has the lower rate of recurrence on larger follow up.

Pakistan Comprehensive Fistula Classification: A Novel Scheme and Algorithm for Management of Palatal Fistula/Dehiscence.

BACKGROUND: It is not easy to find a management-based classification of palatal fistula in the literature. A few attempts have been made to classify the wide variety of fistulae that do not describe the fistula details comprehensively and guide toward its management. The authors have come across a wide variety of fistulae that could not be classified according to any of the prevailing classification systems. The presented classification gives a clear and exact understanding of location and size of fistula/dehiscence. Palatal function has been included as one of the important determinants for devising a management plan. Based on this classification, the authors have proposed an algorithm that encompasses clear guidelines for surgical treatment of these fistulae. METHODS: Over the past 15 years, the authors' team operated on 2537 palatal fistula patients. The medical records of these patients were reviewed to determine the location, size, and velopharyngeal competence. A new classification and algorithm were developed. RESULTS: Of 2537 patients, 2258 had midline fistulae, 208 had lateral fistulae, and 53 had subtotal fistulae. There were 18 patients with dehiscence. Recurrence developed in 181 patients. CONCLUSION: The authors believe that this classification and algorithm can help follow a practical approach to manage palatal fistulae and dehiscence.

Single Bilateral Undivided TRAM Flap for a Bilateral Breasts Reconstruction Including Intermammary Presternal Skin Defect Coverage.

We present a case report of 30-year female presenting with a large skin and soft tissue defect of anterior chest wall, after bilateral mastectomy. Unlike other patients, she also had sternum defect after resection of skin of sternum. She had a 34x17 cm defect of anterior chest when she presented to us. We covered the defect and reconstructed bilateral breasts all with a single paddle bilateral delayed Transverse Rectus Abdominus Myocutaneous (TRAM) flap. Our flap paddle measured 42x21 cm and we observed no tip necrosis.

Medial Sural Artery Perforator Flap: A Versatile Option For Soft Tissue Reconstruction Of Head And Neck And Limbs.

BACKGROUND: To assess the outcome of Medial Sural Artery Perforator Flap (MSAP Flap) as an option for the soft tissue reconstruction of head and neck and limbs. METHODS: This descriptive case series was conducted at Jinnah Burn and Reconstructive Surgery Center, Lahore during October 2016 to August 2017. All patients in whom MSAP flap (free and pedicled) was performed for reconstruction are included. Patients were followed at one week and one month after the discharge and data was entered into the proformas. RESULTS: In total, 18 patients were operated with this flap. Free and pedicled MSAP flap were performed for reconstruction of soft tissue defects in the head and neck and the lower limb. The maximum dimensions of the flap were 14 cm length and 10 cm width. The maximum pedicle length was 16cm. All flaps survived and showed good outcome. There was necrosis of the distal margin of a pedicled flap, but no case of venous congestion and flap failure was observed. The flap donor site was closed primarily in 7 patients while split skin graft was used in the rest of the patients. CONCLUSIONS: The MSAP flap provides a thin skin paddle and has minimal donor site morbidity as compared to the other options. It is a good addition to the armamentarium of perforator flaps which are thin and pliable, can be harvested by two team approaches, under the tourniquet and has a hidden donor site.

Extended Islanded Reverse Sural Artery flap for Staged Reconstruction of Foot Defects Proximal to Toes.

Obective:To assess the outcome of extended delayed reverse sural artery flap for reconstruction of foot defects proximal to toes in terms of flap survival, complication and extended area. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Jinnah Burn and Reconstructive Surgery Centre, Lahore, from February 2015 to April 2017. METHODOLOGY: Cases who underwent delayed sural artery flap were inducted. Preoperative hand-held doppler was done to confirm the location of perforator. Two suitable perforators were chosen to raise the extended flap by crossing the proximal limit in all cases. The pedicle was kept minimum 3 cm wide and perfusion was assessed. Flap was delayed for one week and vaccum-assisted closure (VAC) dressing was applied over wound. The second surgery was performed after one week. Proximal perforator was clamped and ligated after checking adequate perfusion of flap. Flap was insetted into defect. RESULTS: Thirty-two patients were reconstructed with delayed reverse sural artery flap. The mean age of the patients was 26.5 12.2 years. Twenty-four (75%) patients were males and 8 (25%) were females. Twenty-two (68.7%) cases were degloving wounds after road traffic accidents (RTA), 6 (18.7%) were diabetic foot wounds, 4 (12.5%) sustained injury after falling from height and 7 (21.8%) patients had fracture of metatarsals. Twenty-eight flaps were transferred after one week delay, and only in 4 cases, flap were transferred after two weeks. All flaps survived completely. Complications of infection noted in 3 (9.3%) flaps, 3 (9.3%) flaps showed tip necrosis, 2 (6.2%) flaps undergone epidermolysis and only 2 (6.2%) showed venous congestion. CONCLUSION: Delayed islanded reverse sural artery perforator flap is a reliable and versatile option for resurfacing soft tissue defects of lower limb proximal to the toes with lesser complications and extended coverage area.

Distally Based Medial Hemisoleus Flap: Reliable Option for Distal Tibial Wounds.

OBJECTIVE: To determine the success (flap survival as a whole without necrosis or dehiscence up to two months as judged clinically) of distally based medial hemisoleus muscle flap for the coverage of distal tibial defects. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Jinnah Burn and Reconstructive Surgery Centre, AIMC, Lahore, from July 2014 to July 2017. METHODOLOGY: Patients with middle and distal third tibial defects were enrolled and stratified according to the site of the wound in middle or distal third of tibia. Soft tissue coverage was provided with distally based medial hemisoleus muscle flap on which split thickness skin graft was applied. Postoperatively, patients were followed-up after one week of discharge and then fortnightly for at least 2 months. Outcome variable was taken as flap success. RESULTS: Out of 37 cases, flap was successful in 33 patients as complete flap survived with primary wound healing. Partial flap necrosis without dehiscence was seen in 3 cases and partial necrosis of flap with dehiscence in only one case that required another surgery for the defect. Complete flap loss was not seen in any case. CONCLUSION: Distally based medial hemisoleus muscle flap is reliable coverage option for middle and distal third of tibial defects.