Single-Stage Continent Reconstruction of Composite Pericommissural Defects Using a Combination of Pacman-Style Free Radial Forearm Flaps and Modified Elastic Musculomucosal Flaps.

Introduction Based on the cross-innervation of buccal and marginal mandibular branches of the facial nerve, oblique elastic musculomucosal flaps (OEMMFs) can be harvested and used for continent neo-commissure and modiolus reconstructions. The composite pericommissural defects can then be reconstructed with double cutaneous paddles in Pacman-style free radial forearm flap (PFRFF). This novel single-stage continent reconstruction of composite post-excisional commissure and pericommissural (CPECPC) defects is evaluated in this study. Patients and Methods This retrospective cohort study was conducted from April 2016 to March 2019. Forty-two patients underwent this type of reconstruction using a combination of PFRFF and OEMMF for the CPECPC defects. They were followed for an average period of 11.5 months. At the end of the follow-up period, they were assessed using the objective institutional scoring system by two independent observers and final score was computed for each patient. Results The average score obtained at the end of the follow-up period was 11.5 ( p = 0.035) using the institutional assessment scoring system, which evaluated both the overall aesthesis and function of the neo-commissure and modiolus. Conclusions The combination of OEMMF and PFRRF for the single-stage reconstruction of CPECPC defects is a useful addendum for re-establishing the aesthesis and continence at the reconstructed site.

Internal Offloading or Surgical Offloading Adjuvant Techniques in the Reconstruction of Diabetic Plantar First Metatarsal Head Ulcer For Lasting Results.

Introduction Management of diabetic foot ulcers (DFUs) is subverted by recurrences. The main cause for the recurrence of DFUs is the failure to recognize and address all the faulty biomechanics precipitating and perpetuating the ulcer. So, we have devised a protocol for treating the diabetic plantar first metatarsal head ulcer (DPFMHUs) incorporating structured internal offloading procedures in conjunction with reconstruction. Aim The aim of this study was to evaluate our protocol in the management of DPFMHUs. Materials and Methods Fifty-one patients (31 males and 20 females) with DPFMHUs were managed with our protocol in this prospective cohort study conducted from March 2015 to March 2020. All the faulty biomechanics were addressed by tailored internal offloading procedure as per the protocol. Results All patients were followed up for an average period of 23.7 months. Early complications were in the form of wound infection (3 patients, 5.9%) and seroma/hematoma (2 patients, 3.9%). Late complication in the form of recurrence was seen only in one patient (1.9%); rest of the patients had no recurrence (98%). Transfer lesions were noted in six patients (11.8%). Conclusion Our tailored protocol, which addresses all the faulty biomechanics associated with the DPFMHU, may be very helpful in preventing the recurrence and to give lasting results. It is imperative to design a tailored internal/surgical offloading procedure for all deforming forces that are responsible for precipitation and perpetuation of DPFMHUs, in addition to like tissue reconstruction.

Function-Preserving Neurotized Lateral Arm Free Flap in the Reconstruction of Hemiglossectomy Defects.

Introduction and Methods The glabrous, thin, and pliable texture of lateral arm flap with no loss of any axial vessel of the limb renders it a good choice for hemiglossectomy defect reconstruction. The main caveat of this flap harvest is the loss of sensation in the distribution of posterior antebrachial cutaneous nerve (PABCN). In this article, we present two strategic sites and techniques to preserve the integrity of PABCN and at the same time harvesting lateral arm flap with a lengthy lower lateral cutaneous nerve of arm for the neurotization. The outcome of this function-preserving neurotized lateral arm free flap in the reconstruction of hemiglossectomy defects is analyzed and presented in this article. Results Ninety percent of the patients attained grade 3 score in objective assessment, leading to a significant p -value of 0.02 with this technique. All had preservation of sensation in the distribution of PABCN. Conclusion Our technique of harvest and neurotization has brought good functional recovery of the oral cavity with preservation of PABCN.

Distally Based Pedicled Fibula Flap for Reconstruction of Infected Charcot's Midtarsal Collapse-Diabetic Rocker Bottom Foot.

Introduction and Methods Diabetic rocker bottom foot with secondary infection exacts the expertise of a reconstructive surgeon to salvage the foot. The author selected 28 diabetic patients with secondarily infected Charcot's degenerated rocker bottom feet and reconstructed their feet using distally based pedicled fibula flap. Reconstruction was done in a staged manner. Stage 1 surgery involved external fixation following debridement. In stage 2, struts were activated for distraction and arthroereisis. In stage 3, the distally based pedicled fibula was used for reconstruction and beaming of the arches. Results In this retrospective study, the author analyzed the outcome of all 28 patients using the Musculoskeletal Tumor Society Rating (MSTSR) score. The average MSTSR score was 27.536 in an average follow-up of 30.5 months. The limb salvage rate with the author's procedure was 96.4% ( p = 0.045). Conclusion Author's protocol for the staged reconstruction and salvage of the infected diabetic rocker bottom foot, using the pedicled fibula flap, will be a new addendum in the reconstructive armamentarium of the orthoplastic approach.

Retrospective Study of Prosthetic Augmentation Mammoplasty in Transwomen.

Introduction Hormonal therapy and gender-conforming surgeries are the treatments of choice in appropriately selected male-to-female transsexuals. The Prosthetic Augmentation Mammoplasty (PAM) in transwomen is the second most common sex conforming procedure performed in our department. Aim This study was aimed to assess the esthetic outcomes of PAM performed from 2007 to 2017 in 42 transwomen. Patients and Methods It is a retrospective study wherein the documents of 42 transwomen who had undergone PAM were reviewed. Twenty-three transwomen who had pinch fold thickness more than 2.5 cm had undergone subglandular/subfascial (SG/SF) plane augmentation; rest had dual plane augmentation. All the cases were followed-up for an average period of 45 months. A validated institutional score for subjective assessment and objective assessment (by two independent observers) were used at the end of follow-up period. Statistical Analysis Used Student's t -test was used for statistical analysis. Results On an average, 92.85% of transwomen achieved grade-A score with both subjective and objective assessment scoring system. Conclusion PAM gives a finishing and colossal touch for transwomen to orient their somatic sex to psychic sex. To get the best cosmetic outcomes and lasting results the PAM in transwomen has to be made a more reasoning and scientific procedure rather than an emotional and irrational procedure. Author's PAM approach facilitates transwomen to rejoice their veritable total genderness in harmony with their gender identity.

Retrospective Cohort Observational Study on the Single Best Perforator-Based Pacman Flap in the Reconstruction of Stage IV Sacral Region Pressure Ulcers.

Introduction Single best perforator-based Pacman flap (SBPBPF) fortifies the advancement and transposition flap biogeometry principles with robust blood supply of perforator flaps to provide cover for the sacral pressure sore of any dimension. This article describes the biogeometry and technique of raising the SBPBPF. Aim To assess the outcomes of reconstruction of stage IV sacral pressure sore using the SBPBPF. Materials and Methods A preliminary cadaver study was done in 24 gluteal specimens in fresh cadavers to determine the anatomical details of perforators of the perisacral region. From 2015 to 2017, 42 myelopathic patients (40 males and 2 females; quadriparetic n = 2 and paraplegic/paraparetic n = 40) underwent SBPBPF reconstruction of stage IV sacral pressure sore. Their documents were analyzed in this retrospective study. All were followed-up for an average period of 12.5 months. Results Cadaver study revealed significant perforators arising from seven different source vessels in the perisacral region. In the clinical study, average size of the paddle harvested was 168 cm 2 on a single best perforator. On an average, the size of the single best perforator harvested with the flap was 1.5 mm. None had early failures of flaps. Thirty-nine patients had well-settled flaps at the end of follow-up period except three (7%) who developed late recurrence due to loss of compliance with offloading instructions. Two experienced mild collections (flap complication rate was 4.76%) in the immediate postoperative period that healed uneventfully. The overall complication rate was 11.9%. Conclusion SBPBPF is an excellent addendum to reconstructive tool for stage IV sacral pressure sores.

Anatomy of Landsmeer Ligaments-Redefined.

Introduction Landsmeer ligaments play a significant role in synchronizing the movements of the two distal phalanges of the fingers. However, there is considerable controversy in descriptions of its anatomy, function, presence, and clinical applications. Aim To ascertain and redefine the detailed anatomy of Oblique Retinacular (ORL) and Transverse Retinacular ligaments (TRL) and their applied features. Materials and Methods Anatomical dissection study was conducted in 100 cadaveric fingers in 42 cadavers (28 fresh specimens and remaining preserved specimens) under loupe magnification. The whole dorsal digital expansion with attached fibrous flexor sheath was dissected and specimen was examined after thorough saline wash. The dimensions, course, attachment, and configuration were noted in each specimen. The statistical mean was obtained for thickness of the ligaments. The measurements were made using a caliper at the level of the mid proximal phalanx, volar to the proximal interphalangeal (PIP) joint, and dorsal to the distal interphalangeal (DIP) joint. Results By anatomical dissection we have found the following: • The ORL was deep to the TRL. • The ORL had got a check rein effect at the PIP joint, in such a way that extension of the PIP joint causes extension of the DIP joint. • The ORL criss-crossed volar to the A3 pulley of fibrous flexor sheath and formed a good hammock for the PIP joint. This criss-crossing anatomical feature was found in all dissected fingers as an additional normal anatomical feature complementing the classical description of Landsmeer. • Variations in configuration of the Landsmeer ligaments were observed among various fingers. • The Landsmeer ligament was never absent as reported by several studies. Conclusion Contrary to several studies, the ORL was omnipresent in all dissected fingers with considerable variations in dimensions. Complementing the classical description of Landsmeer, we found that there was an additional normal criss-cross anatomical feature of the ORL in all fingers volar to A3 pulley and deep to the TRL. Also, the TRL was present in all the fingers.

Saphenous Artery Perforator/Propeller Flap in the Reconstruction of Perigenual Soft Tissue Defects.

Introduction In this article, we investigate the saphenous artery perforator propeller flap for the reconstruction of perigenual defects. We describe the anatomy of the saphenous artery and the method of raising a perforator propeller flap based on our study and early clinical experience. Aim To assess the effectiveness of the saphenous artery perforator propeller flap in the reconstruction of perigenual defects. Materials and Methods A preliminary cadaver dissection and injection study was conducted to discern the anatomical details of the perforator system of the saphenous vessel in 35 cadaveric specimens in 18 fresh cadavers. From March 2016 to March 2018, 16 clinical cases (5 females and 11 males, in the average age group of 33.5 years) with perigenual defects were reconstructed with saphenous artery perforator propeller flap. They were followed up for an average period of 12.5 months. Results Cadaver study established anterior sartorial perforators as the dominant system of the saphenous vessel and brought to the forefront the type 2 blood supply of the saphenous nerve. All patients had well-settled flaps at the end of the follow-up period, with good return of knee function. Conclusion Saphenous artery perforator propeller flap is a viable option for the reconstruction of defects around the knee joint. Level of Evidence Type V, therapeutic study.

Eril's Branch-Based Perforator Plus Chondro-Cutaneous Flap for Reconstruction of Upper Third Helico-Scaphal Defects: A Clinical and Cadaver Study.

Reconstruction of upper third helico-scaphal defects (HSDs) exacts the expertise of the reconstructive surgeon. These three-dimensional defects deviate from normal facial form and cause a significant impact on the psyche of the patients. The origin, course, and dimensions of the perforators of the Eril's branch arising from superficial temporal vessels (EBSTV) were delineated by dissection and injection study. They were examined in twenty-four adult specimens. A prospective cohort study was conducted from March 2017 to March 2020, including six patients whose upper third HSDs were reconstructed with perforator plus chondro cutaneous flap based on EBSTV. After the debridement of the defect, the perforator plus chondro cutaneous flap was harvested from retro auricular sulcus skin with attached cartilages from triangular fossa and interhelical groove. The donor site was closed primarily, and the flap was rotated onto the defect. Superficial temporal vessels give a constant Eril's branch at the level of the root of the helix (otobasion superioris), which in turn divides into two perforators -superficial (lateral) and deep (medial) perforators. All six patients with post-traumatic upper third HSDs (4 males and 2 females) after reconstruction were followed for an average period of 15 months. The average age was 36.5 yrs. On average, two cartilages of maximum dimensions 3 × 2.5 mm were included in the perforator plus chondro cutaneous flap based on the medial-deep perforator of the EBSTV. In all six cases, the flaps survived without any complications. The average final computed institutional objective and subjective score was 15.67 (excellent results) (chi-square test, the p value was (p = 0.035) significant). The perforator plus chondro-cutaneous flap based on deep medial perforator of EBSTV may be a useful addendum in the armamentarium of plastic surgery. This novel reconstruction technique of upper helical defects provides good shape, size, and aesthesis of the upper external ear.

Single stage reconstruction of post traumatic and post excisional composite perigenual defects using chimeric pedicled propelled osteomyocutaneous fibula flap.

INTRODUCTION: Composite perigenual defects (CPGDs) are exacting the expertise of the reconstructive surgeons. Segmental skeletal defects continue to be a challenge for both orthopedic and plastic surgeons. There are many techniques available for the reconstruction of segmental skeletal defects in the perigenual region. This study explores the outcomes of pedicled chimeric propelled osteomyocutaneous fibula flap reconstruction of post traumatic and post excisional composite perigenual defects (CPGDs) MATERIALS AND METHODS: It was a retrospective study conducted from 2011 to 2016 including 16 patients (5 post excisional defects and 11 post traumatic defects). 14 males and 2 females were included. Ages of the patients were ranging from 24 to 46 years. All had their CPGDs reconstructed with chimeric pedicled propelled fibula osteomyocutaneous flap RESULTS: All 15 patients on an average of 26 months follow-up assumed pain free unrestrictive walking. Fracture of hardware and transferred fibula occurred in one case 2 1/2 years following the surgery. Other patients had good functional recovery in an average of 26 months follow up. The average MSTS score of 15 patients was 23.9. CONCLUSION: This anatomically construed procedure will be addendum to the armamentarium of reconstruction in both post excisional limb salvage milieu and secondary posttraumatic context for the perigenual composite defects. With high healing potential, infection culling capacity, high osteogenic potential and good supportive hardwares the pedicled osteomyocutaneous fibula flap may usher in better outcome in composite perigenual defects reconstruction.