A Single Staged Reconstruction of Upper Eyelid and Eyelashes.

The upper eyelid is a complex structural part of the face that plays an important role in protecting the cornea from drying and damage to preserve vision. The eyelashes are an essential part of the upper eyelid and help in protecting the eyes from dust, foreign bodies, and sweat. Being a part of the face, which is the most noticeable part of the body, both structures hold an important role in reconstructive procedures. Reconstruction of both structures simultaneously is tricky but helps reduce the number of procedures required in achieving an aesthetically acceptable eye. Our techniques describe the use of the paramedian forehead flap with an anterior hairline to reconstruct the upper eyelid and eyelashes in a single stage in a posttraumatic near-total upper eyelid defect with a favorable outcome. Depending on the parting of the patient's hair, the anterior hairline of one side can be included in the distal edge of the flap while raising, which can be inset so that the direction and orientation of the eyelashes perfectly match. Our technique refurbishes an established technique for eyelid reconstruction to include eyelash reconstruction at the same time, thus saving time and resources without any inconvenience to the patient.

Expectation versus Reality on Basic Research Topics in Plastic Surgery Conferences: Gap Analysis.

The idea of attending conferences in our specialty is defeated if the demands are not met. Hence, the authors have tried to sum up the feedback after attending such conferences to give future organizers an insight into the same and ways to rectify the pitfalls by giving guidelines to amend them.

Preoperative Preparatory Talk (PPT): Developing Operative Expertise of Plastic Surgery Trainees by Three Rounds of Preceptor-Trainee Discussions.

Background Plastic surgery training requires the trainee to assist in surgeries to improve their on-table decision making and hone their surgical skills, but this results in an increased risk of intraoperative complications and increased operative time. It is important to have a training method that orients the trainee toward the surgery to ensure patient safety. Materials and Methods A training method called preoperative preparatory talk (PPT) was devised in which the preceptor orients the trainee toward the planned surgery in three phases. Comparison and statistical analysis of mean operative times of four stages of free flap surgeries after PPT and without PPT were done. Objective Structured Assessment of Technical Skill (OSATS) scores of surgical trainees were also documented for surgeries done with and without PPT and statistical analysis was done for comparing these scores. Results Statistical analysis via unpaired t -test confirmed that after applying PPT, there was a significant decrease in time taken in three out of four stages of free flap surgeries: flap planning and harvesting, recipient site preparation and vessel dissection, and flap division and partial inset. Trainees were found to be better oriented toward the surgery which resulted in a better performance on table that was confirmed by statistical analysis of OSATS score via unpaired t -test. Conclusion PPT ensures better learning for the resident and improves patient safety because of better orientation of the operating team toward the procedure and operating steps. This reduces the operative time of free flap surgeries. We recommend this training method to be incorporated in plastic surgery training programs.

Restoring Quality of Life: Assessing the Impact of Free Flap Reconstruction in Coronavirus Disease 2019-Associated Rhino-Orbital Mucormycosis Patients.

Background In India, between May 5 and July 2021, 41,512 cases and 3,554 deaths due to mucormycosis were reported in coronavirus disease 2019 (COVID-19)-infected patients or COVID-19-recovered patients. COVID-19-associated rhino-orbital mucormycosis (CAROM) has been associated with adverse effects that can affect oral health, vision, and physical as well as emotional functioning. After the radical debridement of CAROM and antifungal therapy, reconstructive surgery should be employed to restore function and aesthetics; however, limited clinical data exist on its potential effect on the quality of life (QOL) of these patients. Objective Our objective was to assess the QOL among CAROM patients reconstructed with free flap surgery. Materials and Methods This analysis studied 19 patients of CAROM who had maxillectomy and/or orbital exenteration defects reconstructed with free flaps at a tertiary care center. All these patients were free from any residual disease, as confirmed by tissue biopsy taken from the affected area. The QoL of these patients was assessed 1 week preoperatively and 4 to 6 months postoperatively using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ-HN43) questionnaire module. Results There was a statistically significant improvement in 10 out of the total 19 parameters ( p < 0.05) which include pain in the mouth, problems opening mouth, speech, swallowing, weight loss, dry mouth and sticky saliva, body image, fear of progression, social contact, and social eating. Conclusion The EORTC QLQ-HN43 questionnaire module presented a statistically significant improvement in the functional as well as psychological status of the CAROM patients undergoing reconstruction by free flap surgery.

Leveraging Large Language Models (LLM) for the Plastic Surgery Resident Training: Do They Have a Role?

Introduction Large language models (LLMs) are designed for recognizing, summarizing, translating, predicting, and generating text-based content from knowledge gained from extensive data sets. ChatGPT4 (Generative Pre-trained Transformer 4) (OpenAI, San Francisco, California, United States) is a transformer-based LLM model pretrained on public data as well as data obtained from third-party sources using deep learning techniques of fine tuning and reinforcement learning from human feedback to predict the next text. We wanted to explore the role of LLM as a teaching assistant (TA) in plastic surgery. Material and Methods TA roles were first identified in available literature, and based on the roles, a list of suitable tasks was created where LLM could be used to perform the task. Prompts designed to be fed in to the LLM (specifically ChatGPT) to generate appropriate output, were then created and fed to the ChatGPT model. The outputs generated were scored by evaluators and compared for interobserver agreement. Results A final set of eight TA roles were identified where a LLM could be utilized to generate content. These contents were scored for usefulness and accuracy. These were scored independently by the eight study authors in a scoring sheet created for the study. Interobserver agreements for content accuracy, usefulness, and clarity were 100% for content generated for the following: interactive case studies (generation), simulation of preoperative consultations, and generation of ethical considerations. Discussion LLMs in general and ChatGPT (on which this study is based) in specific, can generate answers to questions and prompts based on huge amount of text fed into the model for training the underlying language model. The answers generated have been found to be accurate, readable, and even indistinguishable from human-generated text. This capability of automated content synthesis can be exploited to generate summaries to text, answer short and long answers, and generate case scenarios. We could identify a few such scenarios where the LLM could in general be utilized to play the role of a TA and aid plastic surgery residents in particular. In addition, these models could also be used by students to obtain feedback and gain reflection which itself stimulates critical thinking. Conclusion Incorporating LLMs into the educational arsenal of plastic surgery residency programs can provide a dynamic, interactive, and individualized learning experience for residents and prove to be worthy TAs of future.

A Systematic Review Comparing Outcomes of Local Flap Options for Reconstruction of Pressure Sores.

INTRODUCTION: Pressure sores are agonizing complications of chronically bedridden patients. The management of these lesions particularly with respect to grades III and IV lesions are chiefly surgical and involves a multidisciplinary approach. Although there are a variety of local flap options, like fasciocutaneous flaps, musculocutaneous flaps, perforator flaps, and combinations of these to choose from, there is a paucity of literature regarding which flap is better among these in terms of complication and recurrence rates. METHODS: The databases searched were as follows: Cochrane Central Register of Controlled trials (January 2000 to July 2020), MEDLINE (January 2000 to July 2020), and EMBASE (January 2000 to August of 2020). Key words used were "pressure ulcer," "flaps," "surgery," "pressure sore" with limits, "human," and "English." Primary outcomes were "overall complication rates" and "recurrence rates." Overall complication was further categorized as flap necrosis, flap dehiscence, infection, and others. RESULTS: Thirty-nine articles were included in the final analysis. There was a statistically significant difference among the various types of flaps for overall complication, flap dehiscence, infection, flap necrosis, and recurrence rates. CONCLUSIONS: Our study indicates that musculocutaneous flaps have lower recurrence rates, and combined flaps have lower complication rates. However, various other factors, like donor site morbidity, initial defect size, operating time, intraoperative blood loss, salvage options in case of recurrence, should also be considered while choosing a flap to reconstruct a defect.

CSF Oculorrhea Presenting as "Tearing" following the Repair of Fronto-Ethmoidal Encephalocele.

INTRODUCTION: Cerebrospinal fluid (CSF) oculorrhea is extremely rare, and very few cases have been reported mostly following trauma. There is only 1 case in the published literature where oculorrhea occurred following the repair of fronto-nasal encephalocele. CASE DESCRIPTION: A six-year-old girl presented with gradually increasing fronto-ethmoidal encephalocele with secondary papulo-nodular changes. She underwent bi-frontal craniotomy with excision of encephalocele sac and herniated gliotic brain followed by dural closure using peri-cranial graft. One month later, she presented again with swelling over the operative site and "tearing" from both her eyes. She was diagnosed with CSF oculorrhea. After failing conservative management, lumbar drain was inserted and kept on continuous drainage. Oculorrhea stopped with lumbar drain but restarted with its removal. Therefore, theco-peritoneal shunt was placed, following which oculorrhea stopped. She is doing well at 5 months' follow-up. CONCLUSION: CSF oculorrhea must be considered by the pediatric neurosurgeons in any patient who presents with "tearing" following the repair of an anterior encephalocele.

Total Gluteal Reconstruction with "IGA-based V-Y Myocutaneous Advancement Flap".

Introduction A 44-year-old man was presented with chronic discharging multiple perianal fistula and squamous cell carcinoma of the left buttock. Report The patient was subjected to wide local excision of the entire left gluteal and adjacent sacral regions and reconstruction with extended island inferior gluteal artery based V-Y myocutaneous advancement flap. Result and Conclusion Extended island inferior gluteal based V-Y flap can be a good option for extensive defects involving the gluteal region and the sacrum.

Unclassified congenital deformities of the external ear.

Congenital ear deformities are a common entity. They are found in isolation or as a part of syndrome in patients. They may involve the external, middle or inner ear or in any of these combinations. Three patients of different ages presented with deformities including mirror image duplication of the superior auricle, unclassified deformities of ear lobule (wavy lobule) and deformity of superior auricle with unclassified variety of lateral ear pit. This article highlights that there are further cases of ear deformities that are noticed in the general population who come for cosmetic correction, and hence, there is a need for further modifying the classification of ear deformities.

An important superficial vein of the radial aspect of the forearm: An anatomical study.

INTRODUCTION: The superficial veins of upper limbs are seldom talked about. They are always avoided quoting them to be variable in anatomy. Other than the cephalic and basilic veins, no other superficial vein has caught the eyes of anatomists and other health professionals significantly. This article tries to explain the importance of a superficial vein that closely traces the radial vessels and explains its possible use in microvascular reconstruction. MATERIALS AND METHODS: The forelimbs of 26 upper limbs of fresh frozen cadavers were dissected out. The anatomy of the superficial vein that follows the radial vessels was traced out from wrist to cubital fossa. Their relation to the deep venous system and cephalic veins was followed and documented. RESULTS: All the 26 upper limbs showed the existence of the superficial vein that follows the radial vessels. The study also revealed the existence of venous perforators which are in turn the communication channels between the deep and superficial venous systems. CONCLUSION: The existence of the surface vein can logically hold an explanation for flap failure or success when one vein anastomosis is contemplated for radial forearm-free tissue transfers.

Columellar-Frenulum Angle - A Significant Clinical Parameter in Assessing the Degree of Severity in Unilateral Cleft Lip.

OBJECTIVES: The study was carried out to learn if the columellar-frenulum angle could be used as one of the most important anthropometric measurements to predict the clinical severity in unilateral cleft lip patients. SETTINGS AND DESIGN: This is a prospective case series conducted at Banaras Hindu University, Varanasi, India. METHODS AND MATERIAL: The study was based on the Thomson and Reinders criteria (1995), and various anthropometric measurements, including the columellar-frenulum angle, were measured. A total of 30 patients (21 boys and 9 girls) were included in the study. The ages of the children varied from 4 months to 15 years. The left side was affected in 18 patients, and 2 gave a significant positive family history. All the patients were subjected uniformly to Tennison's cleft lip repair. Patients with strictly unilateral complete cleft lip and palate were included in the study. Microform clefts, incomplete cleft lips, and bilateral clefts were excluded from the study. STATISTICAL ANALYSIS: The data was analyzed using Pearson's correlation coefficient. RESULTS: The CF angle correlated negatively with the soft tissue defect of the cleft, cutaneous lip length, and vermilion lip length discrepancies from normal and soft tissue width just behind the alveolus. CONCLUSIONS: CF angle promises to offer a method by which prognosis of clefts can be predicted in terms of its severity in patients with unilateral cleft lip.

A pregnant patient with fetal distress with severe post burn contracture of anterior trunk and perineum: A surgeon's nightmare!

INTRODUCTION: A case report of a pregnant lady in the third trimester, presenting in the emergency with absent fetal movements is being described. A multi-speciality expertise was involved and a full term female baby was delivered. PRESENTATION: The patient presented in a Government hospital, Dehradun, India. At the time of presentation the fetal heart sounds were absent and subsequently the severe post-burn deformity involving the anterior trunk, perineum and thighs were discovered. MANAGEMENT: Immediately a multi-speciality approach involving the plastic, obstetrics and pediatrics field were called for and an emergency caesarean with simultaneous contracture release with split skin grafts were performed after optimizing the patient for surgery. CONCLUSION: This is one of the first case reports reporting this rare combination of post burn contracture of trunk and perineum with fetal distress requiring emergency caesarean section along with release of abdominal and perineal post-burn contracture. This case interestingly reinforces that in such complicated cases a systematic and a combined multi-speciality approach still holds the key to patient's treatment even in district hospitals.

An intercontinental comparison of the influence of smoking on the occurrence of nonsyndromic cleft lip and palate: a meta-analysis and systematic review.

BACKGROUND: The influence of smoking on nonsyndromic clefts has been a topic of research for many years. However, few studies have investigated the effect of smoking on causing clefts in different gene pools. METHODS: A meta-analysis was conducted of case-control studies related to smoking. Keywords such as "clefts," "cleft lip," "cleft palate," "orofacial cleft," and "smoking" were used to search the MEDLINE, Embase, and Cochrane databases. RESULTS: In total, 51 articles were reviewed. The RevMan software was utilized for the analysis, and the Mantel-Haenszel method was employed to pool the odds ratios (ORs) and 95% confidence intervals. Although the overall OR, a measure of the association between exposure and outcome, was higher for smokers than for non-smokers, this association was significantly stronger in individuals from Asia and South America (1.73), and lowest in Europe (1.31). Among active and passive smokers in Asia, the OR was approximately 0.93, indicating an equivalent impact from both types of smoking. CONCLUSION: This analysis indirectly suggests that restriction measures targeting both active and passive smoking are crucial in Asia.

Quantifying nasal deformities using a novel mathematical method to complement preoperative assessment in rhinoplasty patients.

BACKGROUND: Rhinoplasty enhances facial symmetry and functionality. However, the accurate and reliable quantification of nasal defects pre-surgery remains an ongoing challenge. AIM: This study introduces a novel approach for defect quantification using 2D images and artificial intelligence, providing a tool for better preoperative planning and improved surgical outcomes. MATERIALS AND METHODS: A pre-trained AI model for facial landmark detection was utilised on a dataset of 250 images of male patients aged 18 to 24 who underwent rhinoplasty for cosmetic nasal deformity correction. The analysis concentrated on 36 different distances between the facial landmarks. These distances were normalised using min-max scaling to counter image size and quality variations. Post-normalisation, statistical parameters, including mean, median, and standard deviation, were calculated to identify and quantify nasal defects. RESULTS: The methodology was tested and validated using images from different ethnicities and regions, showing promising potential as a beneficial surgical aid. The normalised data produced reliable quantifications of nasal defects (average 76.2%), aiding in preoperative planning and improving surgical outcomes and patient satisfaction. APPLICATIONS: The developed method can be extended to other facial plastic surgeries. Furthermore, it can be used to create app-based software, assist medical education, and improve patient-doctor communication. CONCLUSION: This novel method for defect quantification in rhinoplasty using AI and image processing holds significant potential in improving surgical planning, outcomes, and patient satisfaction, marking an essential step in the fusion of AI and plastic surgery.

Comparative analysis of free vascularized fibula grafting and Ilizarov bone transport in management of segmental long bone defect of the lower limb: A systematic review and meta-analysis.

Introduction: Reconstruction of segmental defects of long bones is a daunting task for surgeons. Bone transport with the help of Illizarov external fixator and vascularized free fibula flap are some of the most discussed and valid options for the same. Both techniques have their limitations and overlapping indications. However, there has been no objective evidence in the manner of a systematic review supporting one treatment method over the other. Aim: This systemic review is aimed to compare the bony union, functional outcomes, and complications of Illizarov bone lengthening and free fibula flap performed for segmental bone defects of long bones of the leg. Methods: A comprehensive search was done for all studies published before May 2023. Any observational study comparing bone transport based on Illizarov external fixator and free vascularized fibula grafting techniques for treating lower limb long bone segmental defects was entailed in this study. Results: This systematic review comprised of five retrospective studies. A total of 96 patients were treated by the Illizarov-based bone transport technique and 72 patients were treated by the free vascularized fibula grafting technique. The free vascularized fibula grafting technique yielded a shorter mean time to union (average difference 9.3 months), relatively shorter external fixator time (average difference 5.32 months), and external fixator index (average difference 0.57 months/cm). However, there was no difference in terms of bony and functional outcomes between both techniques when used for the reconstruction of bony defects in the lower limb. Total number of complications was 68 % higher in bone transport with Illizarov external fixator. However, the rates of non-union didn't differ between the groups. Conclusion: The free vascularized fibula grafting technique had a lesser time to bony union, shorter time for external fixator application, and lower incidence of complications. However, the functional and bony outcomes didn't differ between both techniques. Level of evidence: Level 4.

Healing Assessment of Spinal Tuberculosis: A Systematic Review.

OBJECTIVE: Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB. METHODS: A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study. RESULTS: Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing. CONCLUSIONS: Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.

Introduction of Spring-Assisted Cranioplasty for Bicoronal Synotosis in India: Description of First Case and Our Learning Experience.

Background: Various surgical techniques for cranial reconstruction of patients with bicoronal synostosis have been suggested. The outcome is, however, still often suboptimal. Methods: In a 5-month-old child with apert syndrome, following a craniotomy incision, lambdoid suturotomy was done bilaterally. Two springs were implanted bilaterally over the lambdoid sutures. Cephalic index was obtained from three-dimensional computed tomography scans, and photographs were analyzed for aesthetic evaluation. Result: The preoperative calvarial shape was hyperbrachycephalic. The CI improved from 92 to 83 units. Duration of surgery was 1 h 45 min, blood loss was 30 mL, and total hospital stay was 3 days. No major complications were observed. Spring removal was done at 6 months postoperatively and frontoorbital advancement performed. Conclusion: Spring-assisted cranioplasty for bicoronal synostosis is a safe and elegant technique, is less invasive than many other cranioplasties, and results in marked improvement in the calvarial shape.