Division of Fasciocutaneous Pedicled Flaps-Is It Time to Change Practice?: A Prospective Randomized Controlled Trial.

INTRODUCTION: The study was carried out to evaluate the safety of early division of the pedicled flaps and to identify the optimum day of division. METHODS: This prospective, parallel arm, open-label, noninferiority, randomized controlled trial was carried out from January 2019 to July 2020. All patients (age, ≥5 years) undergoing reconstructive procedures using pedicled flaps were randomized in 1:1 ratio to receive either early division or conventional division protocol. In the early-division group, the flap perfusion, if satisfactory on day 8 by clinical and thermographic methods, a clamp was applied on the pedicle. The clamp was gradually tightened to produce controlled delay, and perfusion assessment was repeated after complete tightening. If satisfactory, the flaps were divided. Primary endpoints were flap at 24 hours after division, day of division, and day of complete inset of the flap. Secondary end points included perfusion of the flap on day 8, morbidity parameters (wound infection/suture dehiscence, need for secondary surgery and donor site morbidity), quality of life, and function scores. RESULTS: Thirty-five patients were included in each group. The 2 groups were similar in terms of various demographic, clinicopathological variables, defect and flap characteristics. The flap survival rate was similar (P = 0.31) between the early (34/35) and standard (35/35) division groups. The early-division group had a significantly early mean day of flap division (mean difference of 12.74 days; P < 0.00001) and complete flap inset (mean difference of 12.09 days; P < 0.00001). All flaps had satisfactory perfusion on day 8. The wound infection rate was 1.33 times significantly higher in the conventional group (P = 0.033). There was a higher incidence of donor site morbidity (9% vs 0%) in the conventional group when compared with the early division group. The quality of life and function scores at 3 weeks (mean difference 2.37; P < 0.001) and 6 weeks (mean difference 3.76; P < 0.001) and adjacent joint stiffness were significantly higher in the early division group when compared with conventional group. CONCLUSIONS: The pedicled flaps can be divided significantly early at an average duration of 10 to 11 days after flap inset with increased patient satisfaction rate and with a reduced postoperative morbidity. The authors have included a diversity of pedicled flaps used in different anatomic locations. By using stratified block randomization, we could ensure that the distribution was similar between the 2 groups, thus minimizing the heterogeneity in the analysis. This could also potentially indicate the usefulness of the controlled delay technique, irrespective of the anatomic location and type of the flap.

An Innovative Skin Simulation Model to Augment Competency-based Training in Facial Plastic Surgery.

Introduction Competency-based medical education (CBME) approach in the medical curriculum has been introduced globally with the goal of providing flexibility, accountability, and learner-centeredness among medical learners. Traditional surgical skill training in most places has relied on "see one, do one, teach one model," while simulation model-based training has been shown to improve competencies in surgical trainees. We wanted to assess the usefulness of a hydrophilic barrier adhesive foam wound dressing as a novel skin simulation model for learning biomechanics and practice of cutaneous flaps among plastic surgical resident trainees at our institute. Materials and Methods An absorbent, soft polyurethane foam pad located centrally upon a larger polyurethane membrane, coated with a hydrocolloid adhesive, forming an island dressing, was used as a simulation model for this study. It was obtained from the hospital store either after or nearing their expiry dates of clinical use. Plastic surgery residents in different years of training were invited to participate in a simulation workshop, using this novel model, and give their feedback. Results Seventeen residents in different plastic surgery training levels participated in the workshop and gave their feedback on the skin flap simulation model. The simulation model received extremely high (100%) scores on two parameters, namely, utility for flap and suture practice and high scores (88%-94%) for texture, ability to mark, and improving confidence among trainees. Conclusions Adhesive bilayer polyurethane foam can be used as a novel cutaneous skin flap simulation model for understanding the biomechanics of skin flaps and cutaneous flap practice.

The Impact of "COVID-19" and "Webinar Pandemic" on Plastic Surgery Practice in Teaching Institutes and Resident Training-A Multicentric Perspective.

Introduction The study was carried out to quantify the changes induced by the pandemic in plastic surgery practice and training and to study the impact of the webinars on plastic surgery education from a residents' perspective. Methods In this multicentric study, the number and type of surgeries, cause of injuries, and their regional variation during the coronavirus disease 2019 (COVID-19) period (February-September 2020) were compared with pre-COVID-19 time. An online survey on the impact of webinars was conducted for plastic surgery trainees across the country. Results There was a significant reduction in total number of surgeries ( p = 0.003). The procedures for hand ( p = 0.156), faciomaxillary injuries ( p = 0.25), and replantations ( p = 0.46) were comparable; there was a significant reduction in combined orthopedic-plastic-surgical procedures ( p = 0.009) during the pandemic. There was a significant reduction in road accidents ( p = 0.007) and suicidal injuries ( p = 0.002) and increase in assault ( p = 0.03) and domestic accidents ( p = 0.01) during the COVID-19 period. A usefulness score of >8 was given for the webinars by 68.7% residents. There was no significant difference in perception of utility when correlated with the academic program at their institutes ( p = 0.109); 92% opined webinars should continue in post-COVID times. Conclusion There was a drastic reduction in number of elective and emergency procedures during the COVID-19 time, negatively affecting resident training program. Majority of residents felt that webinars could prove a useful adjunct to training in formal training program in post-COVID-19 scenario.

Use of Islanded Supratrochlear Artery Component Paramedian Forehead Flap and Cranial Bone Graft for Composite Nasal Defect Reconstruction.

ABSTRACT: The authors present a case series of patients with composite loss of nasal skin cover and lining following road accidents. The nasal skeletal framework in all these cases was also severely communited. The reconstruction of all the these was achieved in 1 operation. The authors have utilized islanded supratrochlear artery based paramedian forehead skin and pericranial flap for reconstruction of both skin and lining defects. The nasal skeletal framework was restored with the help of cantilevered split cranial bone graft. In all but 1 patient, the reconstruction was done in the emergency setting at the time of initial admission itself. One patient had infected wound that necessitated an initial debridement and split skin grafting. In this case, the definitive reconstruction was done after a gap of 3 months.A long-term follow-up of these patients is presented.

Clinical Outcomes of Surgical Management of Primary Brachial Plexus Tumors.

Introduction This study evaluates the clinical presentation, tumor characteristics, and clinical outcomes of surgically treated benign and malignant brachial plexus tumors (BPTs). Methods A prospective study of patients with BPTs from June 2015 to August 2020 was conducted. All patients underwent surgical resection with microneurolysis and intraoperative electrical stimulation to preserve the functioning nerve fascicles. Results Fourteen patients with 15 BPTs underwent surgical resection. Mean age was 37.8 ± 12.3 years; with male to female ratio 4:10. The clinical presentations were swelling (100%), pain (84.6%), and paresthesia (76.9%). The lesions involved roots (5/15), trunk (5/15), division (1/15), and cords (4/15). Thirteen patients had benign pathology (8 schwannomas, 3 neurofibromas, 2 lipomas) and two had malignant neurofibrosarcoma. Gross total resection was achieved in all cases except a dumbbell tumor. The mean follow-up period was 24 ± 5 months. Postoperatively, all patients reported improvement in pain and paresthesia with no new sensory deficit. All patients had developed initial motor weakness (Grades 2-4); however, full power (Grade 5) was recovered by 3 to 5 months. Conclusion Total resection can be achieved by appropriate microneural dissection and electrophysiologic monitoring and is potentially curative with preserving function.

Assessment of Clinical and Histological Changes in the Skin Paddle of Pectoralis Major Myocutaneous Flap in Intraoral Reconstruction: A Prospective Cohort Study.

PURPOSE: This study was carried out to characterize the clinical and histological changes in the cutaneous portion of the transferred pedicled pectoralis major myocutaneous flaps used in intraoral reconstruction in patients with head and neck malignancy. METHODS: This was a prospective cohort study carried out from July 2016 to 2018. All patients underwent ablative surgery for oropharyngeal cancers and primary reconstruction with pedicled pedicled pectoralis major myocutaneous flaps. The intraoral flaps were examined for color, texture, presence of hair, chronic inflammatory changes, and ulceration. At 12 months, incisional biopsies were taken from the skin paddle of the intraoral flap and contralateral normal buccal mucosa, and flap histology was compared with that of the contralateral buccal mucosa. RESULTS: Twenty patients were included in the final analysis (M/F, 4:1; mean ± SD age, 51.38 ± 6.76 years). Fourteen flaps resembled oral mucosa, 3 had a mixed appearance of both skin and mucosa, and 3 had appearance of normal skin at 1 year follow-up. The epidermis and stratum corneum were retained in all the flap biopsies; however, severe attenuation was noted in 7 patients (had mucosal appearance) but was significantly different from oral mucosa(P = 0.0003). Cutaneous appendages were found in all the flap epithelia. Thirteen flaps showed grossly attenuation, of which 11 patients had a gross appearance resembling oral mucosa and 2 had a mixed appearance. The biopsies showed varied degree of chronic changes like desquamation in around 35% (7 patients), hyperkeratosis in 35% (7 patients), and chronic candidiasis in 30% (6 patients). CONCLUSIONS: Although the intraorally transferred flaps demonstrate a morphological appearance similar to oral mucosa, there is a histological preservation of skin elements and architecture.

Prospective Analysis and Comparison of Periareolar Excision (Delivery) Technique and Pull-Through Technique for the Treatment of Gynecomastia.

BACKGROUND: Gynecomastia is one of the most common disorders affecting adolescent and adult males. It is a benign disorder but has severe psychological manifestations like low self-confidence, depression, anxiety and social phobia in patients suffering from gynecomastia. Different surgical techniques have been described utilizing a variety of incisions, excisions, lipectomy and liposuction methods. Very frequently, these methods are combined for the gynecomastia treatment with variable reported results. However, there is a lack of studies comparing these techniques. The present study was planned to compare cases of gynecomastia treated by liposuction with periareolar excision (delivery technique) and liposuction with a pull-through technique. METHOD: A prospective randomized control study was conducted at a tertiary care hospital on 20 patients with gynecomastia. The patients were assigned to either liposuction with periareolar excision (delivery technique) or liposuction with pull-through technique. Anthropometric analysis and breast evaluation questionnaire (BEQ) scores were analyzed and compared before and after the surgery. RESULTS: The majority of the study subjects were between 21 and 30 years of age. Low self-confidence was the main reason for surgery in most of the cases. Twelve patients had gynecomastia grade IIa and eight had grade IIb. Both groups had similar responses to BEQ scores before and after the surgery with no statistically significant difference. A statistically insignificant difference was observed between the groups on comparison of anthropometric analysis preoperatively and postoperatively. The mean lipoaspirate volume was 280 ml for the pull-through technique and 367 ml for the periareolar excision technique. No complications were observed in cases operated on by the pull-through technique, while two cases (10%) operated on by the periareolar excision had hematomas. CONCLUSION: Both techniques provide excellent cosmetic results with low risk of complications in both small and moderate breast enlargement with skin excess. The pull-through technique combines the benefits of direct excision of glandular tissues along with the minimally invasive nature of liposuction. Thus, performing the procedure via a single incision without the use of drains is a safer alternative to traditional liposuction with the periareolar excision technique. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Primary lymphangioma circumscriptum of the vulva presenting as warty plaques.

Lymphangioma circumscriptum is a benign hamartomatous malformation involving the lymphatic system of skin and subcutaneous tissue. It can involve any part of the body with maximum predilection for proximal parts of limbs. Vulvar involvement is quite infrequent. Based on the aetiopathogenesis, it can be either primary or secondary, with the secondary form being relatively more common in vulva. We report an exceedingly rare case of primary lymphangioma circumscriptum in a post-menopausal female presenting with multiple warty, papulo-nodular lesions on both labia majora. The patient was diagnosed histopathologically and managed surgically by wide local excision with primary closure.

Use of Modified Islanded Paramedian Forehead Flap for Complex Periocular Facial Reconstruction.

The paramedian forehead flap is a workhorse flap for reconstructing the nose and periorbital regions. Many variants are described including an islanded flap. However, eyebrow reconstruction is not usually performed with these flaps. The authors describe a patient suffering from postburn scarring medial to the left eye, including loss of the left eyebrow. He underwent a single-stage transfer of the paramedian forehead flap. The flap incorporated scalp hair, which restored the missing eyebrow hair after transfer. The donor defect closed primarily. The paramedian forehead flap is amenable to customization by including a segment of hair-bearing scalp to concomitantly reconstruct the nasal dorsum and eyebrow.

Distraction Lengthening of First Metacarpal in Traumatic Thumb Amputations.

Introduction Based on the level of the thumb loss, phalangization, toe-to-thumb transfer, pollicization, and distraction callotasis of the first metacarpal are the various options available for reconstruction. The aims of the study were to observe the length gained in the distraction process, duration of treatment required, functional recovery in the form of pinch strength, sensations, and patient satisfaction. Patients and Methods It was a prospective study of 10 patients of thumb amputation, conducted from January 2014 to July 2015. The patients' age, mode of injury, level of amputation, and advantages and disadvantages of distraction callotasis were evaluated. Results The most common etiology of thumb loss was domestic accidents while working with a chaff cutter. The total duration of treatment was 124 (93-165) days and the mean gain in length was 25 (20-28) mm. The pinch strength increased from a mean of 0.91 to 2.06 kg, i.e., a 44.17% improvement from preoperative pinch strength. All of our patients retained their sensations of the reconstructed thumb post distraction. Conclusions Among many options for thumb reconstruction, distraction callotasis is a simple and safer option in the selective group of patients who are not keen on toe-to-thumb transfer which provide a significant improvement. The longer duration of treatment is the disadvantage associated with the need for proper counselling beforehand.

Primary Nasal Reconstruction in Self-Inflicted Nasal Injury.

Self-inflicted injury of the nose is extremely rare. It may be associated with severe psychopathology and suicidal ideation. The authors report a case of a 24-year-old man, who presented with soft-tissue loss over both the alae of his nose. He had cut off the alar rims with an ordinary razor blade. He was overtly concerned about his nose being excessively broad and fat. A diagnosis of body dysmorphic disorder with nonsuicidal self-injury was made. Patient was observed during 72 hours in hospital with psychiatric support and local dressings. The authors undertook primary nasal reconstruction with nasolabial flaps on both sides for coverage. In conclusion, self-inflicted nasal injury mandates a judicious balancing of psychiatric support and surgical reconstruction. This can prevent untoward sequelae including further self-harm and suicide.

Craniofacial surgery in a tertiary care center in India.

Craniofacial surgery, one of the newest subspecialties of plastic surgery, has taken roots in India. The author, after having trained with Dr Ian Jackson at USA, started this facility in Chandigarh at the Postgraduate Institute of Medical Education and Research in 1995. The hospital caters to a population of approximately 100 million. To date, approximately 1000 major craniofacial procedures have been performed. A wide spectrum of cases belonging to congenital and acquired craniofacial deformities have been managed and followed up over a long period. The pattern of these deformities is different from those seen in the Western world. The complication rate has been comparable to any craniofacial unit in the developed countries. We have suggested ways to augment the existing facilities in India.

Changing trends in plastic surgery training.

BACKGROUND: The currently available training models are being put to scrutiny in India today, both by the residents and the teachers. Plastic surgery specialty was created primarily for reconstructive purposes but the society always perceived it from a cosmetic angle, particularly in the post second world war era. As a result, there is a need to redefine the goals of plastic surgery training in the present times so that the plastic surgeon is "future ready" to meet the needs of society and the market forces. MATERIALS AND METHODS: The author has reviewed the currently available literature on plastic surgery training from India and the western countries. An attempt has been made to study opinions from the teachers and the trainees. The modules currently available in India and abroad have been analyzed and a suggestion has been made for drafting training programs that would meet the demands of the society as well as prepare the resident both for the aesthetic and reconstructive practice. CONCLUSIONS: The plastic surgery training needs to be more vibrant and in tune with the changing times. While maintaining its core nature, the current predominantly reconstructive modules need to incorporate the aesthetic content. The evaluation should be both knowledge and competence based. The teachers need to be educated in the various teaching methods that are more applicable to grown up residents. There is a need to find ways to attract talented people in the academic plastic surgery.

Exploring the efficacy of a novel prebiotic-like growth promoter on broiler chicken production performance.

This study attempts to isolate a candidate growth promoter from the ovine paunch waste and scrutinize its effects on the production performance of broiler chickens as compared to mannan-oligosaccharide (MOS), a prebiotic, and lincomycin, an antibiotic growth promoter (AB). The paunch waste collected from slaughtered sheep was processed to remove particulate matter. The clarified liquid was then added to an excess of ethanol (1:9 ratio), and the resultant precipitate {(novel growth-promoting paunch extract (NGPE)} was collected, dried, and stored. In vitro increase in cell density for probiotic bacteria viz. Lactobacillus rhamnosus and Enterococcus faecalis (Log10 CFU/ml) were significantly higher (P < 0.01) in NGPE supplemented media (2.78 ± 0.11 and 2.77 ± 0.10) as compared to that on MOS (1.28 ± 0.05 and 2.49 ± 0.09) and glucose (1.09 ± 0.04 and 1.12 ± 0.04) supplemented media. In the in-vivo trial of six weeks duration with broiler chickens (Cobb-400), NGPE supplementation resulted in significantly higher growth in weeks IV (P < 0.05) and VI (P < 0.01) of age in comparison to MOS and AGP supplemented groups, a lower (P < 0.01) cumulative feed conversion ratio in comparison to MOS supplemented groups, and a higher (P < 0.01) cumulative protein efficiency ratio compared to MOS and AGP supplementation. NGPE supplementation also lowered lipid peroxidation (P < 0.01), increased reduced glutathione activity (P < 0.01) in chicken erythrocytes, and boosted the lactic acid bacteria count in the cecal contents (P < 0.01). This is the first report of the isolation of a paunch waste extract that increased the in vitro growth of probiotic bacteria and improved the production performance of broiler chickens.

Extensive ulnar nerve necrosis: a complication of tuberculoid leprosy.

Pure neural leprosy without cutaneous manifestations is a relatively rare manifestation of leprosy. It can present as a mono- or poly-neuritis with sensory and/or motor impairment. Neural leprosy may or may not be associated with thickening of the involved nerve. We report the case of a 14 year old boy with extensive ulnar nerve necrosis who was diagnosed to have tuberculoid leprosy. What makes this case unique is that we have here a case of pure neural leprosy with a single nerve turned 'necrotic'.

A randomized study of surgical site infiltration with bupivacaine or ketamine for pain relief in children following cleft palate repair.

BACKGROUND: Wound infiltration with ketamine reduces postoperative pain after tonsillectomy by NMDA receptor blockade and local anesthetic effect. OBJECTIVES: To evaluate the postoperative analgesia after surgical site infiltration with bupivacaine or ketamine in children undergoing cleft palate surgery. MATERIALS AND METHODS: After institutional ethics committee approval and parental consent, 50 ASA-1 children of age 1-6 years undergoing palatoplasty were included in this prospective randomized double-blind study. A standardized technique of general anesthesia was used. The surgical site was infiltrated with either 2 mg·kg(-1) of bupivacaine (Group B) or 0.5 mg·kg(-1) of ketamine (Group K). Pain (Children Hospital Eastern Ontario Pain Score), sedation, dysphagia, nausea, vomiting, and sleep pattern were assessed postoperatively up to 24 h. RESULTS: CHEOPS scores were similar in both the groups up to 12 h but were lower with ketamine compared with bupivacaine at 24 h postoperatively (P = 0.01). Fewer children required rescue analgesics in Group K (28%) than in Group B (64%; P < 0.01). The time to first rescue analgesic and the amount of analgesics used in 24 h were similar in the two groups. Fewer children suffered from dysphagia in Group K (52%) than in Group B (88%; P < 0.01). More children in Group B had disturbed sleep than in Group K at 6 (88% vs 56%; P = 0.012) and 12 h (60% vs 24%; P = 0.01) postoperatively. None of the children had deep sedation, desaturation or respiratory depression. CONCLUSION: Surgical site infiltration with either bupivacaine or ketamine provides adequate analgesia and is devoid of major side effects. Ketamine is superior to bupivacaine in terms of requirement of rescue analgesic, peaceful sleep pattern and early resumption of feeding.

Thurston syndrome: an uncommon disorder presenting with common abnormalities.

This article describes an infant who had a combination of malformations. The boy had a median cleft of the lip, cleft of the soft palate, microcephaly, and ulnar polydactyly of both hands and feet. All of these are relatively commonly encountered in any plastic surgical outpatient department. However, the combination of such abnormalities is encountered extremely rarely. Thurston syndrome is one of the several oral-facial-digital syndromes. A brief literature review of Thurston syndrome and salient features of oral-facial-digital syndromes are discussed.