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.

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 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.

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.

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.

An overview of lower limb cellulitis in an acute medical ward-a few lessons we can learn.

Lower limb cellulitis is a common cause for hospital admissions. In this retrospective study, we assessed the characteristics and outcome of patients admitted in an acute medical unit. The mean duration of treatment was 10.48 days, with 95.5% receiving antibiotics for more than 5 days. Mean length of stay (LOS) was 5.19 days. 12-month readmission rate was higher in patients with diabetes, chronic kidney disease (CKD) and previous stroke. Diabetes, CKD, previous stroke, and elevated procalcitonin levels were independently associated with prolonged admission (>3 days).

Surgery for giant tumours of the breast: a 15 year review.

BACKGROUND: Giant tumours of the breast tend to occur in the adolescent age group. Racial predilection has been noted in the literature. The mass often occupies most of the breast, leading to its distortion. Many authors have advocated a mastectomy for benign tumours that severely distort the breast. Giant benign tumours when treated by simple excision risk persistence of asymmetry. To avoid this asymmetry, some authors have resorted to excision and immediate reduction mammaplasty. The aim of this retrospective study was a report on giant tumours of the breast presenting to a plastic surgery unit and to analyse demographic factors, clinical presentations, tumour pathology, management, complications, as well as patient and breast outcomes. METHODS: Medical records of patients with giant tumours were retrospectively analysed for assessing demographic factors, clinical presentation, tumour pathology, the technique of surgery performed and patient and breast outcomes in a single hospital setting. Breast outcomes were rated by panel of 4 experienced plastic surgeons using the 4 Point Likert scale. Their ratings were statistically analysed for inter-rater agreement. RESULTS: Twenty-three subjects were identified to have giant tumours of the breast. Of these South African patients, 19 were black, 3 were Indian and 1 was of mixed ethnicity. The age range was 12-49 years (y) with an average of 19y. All masses were palpable. The final pathological diagnosis was fibrocystic disease in 3, giant fibroadenoma in 14, phyllodes tumour in 4, and hamartoma in 2. The size range was 10-45 cm with a median size of 18 cm. All but one patient had simple excision followed by immediate reduction mammaplasty. Twenty patients were assessed after operation. A minimum of 1 to a maximum of 4 patients per reviewer showed unsatisfactory outcomes and a minimum of 18 to a maximum of 21 patients per reviewer showed satisfactory to excellent outcomes. The overall agreement between assessors for this was 84%. CONCLUSION: Benign giant tumours (> 10 cm) of the breast are suitably managed by excision of the mass and a reduction mammoplasty technique of reconstruction.

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.

Surgery for giant tumours of the breast: a 15 year review

Background: Giant tumours of the breast tend to occur in the adolescent age group. Racial predilection has been noted in the literature. The mass often occupies most of the breast, leading to its distortion. Many authors have advocated a mastectomy for benign tumours that severely distort the breast. Giant benign tumours when treated by simple excision risk persistence of asymmetry. To avoid this asymmetry, some authors have resorted to excision and immediate reduction mammaplasty. The aim of this retrospective study was a report on giant tumours of the breast presenting to a plastic surgery unit and to analyse demographic factors, clinical presentations, tumour pathology, management, complications, as well as patient and breast outcomes.Methods: Medical records of patients with giant tumours were retrospectively analysed for assessing demographic factors, clinical presentation, tumour pathology, the technique of surgery performed and patient and breast outcomes in a single hospital setting. Breast outcomes were rated by panel of 4 experienced plastic surgeons using the 4 Point Likert scale. Their ratings were statistically analysed for inter-rater agreement.Results: Twenty-three subjects were identified to have giant tumours of the breast. Of these South African patients, 19 were black, 3 were Indian and 1 was of mixed ethnicity. The age range was 12­49 years(y) with an average of 19y. All masses were palpable. The final pathological diagnosis was fibrocystic disease in 3, giant fibroadenoma in 14, phyllodes tumour in 4, and hamartoma in 2. The size range was 10­45 cm with a median size of 18 cm. All but one patient had simple excision followed by immediate reduction mammaplasty. Twenty patients were assessed after operation. A minimum of 1 to a maximum of 4 patients per reviewer showed unsatisfactory outcomes and a minimum of 18 to a maximum of 21patients per reviewer showed satisfactory to excellent outcomes. The overall agreement between assessors for this was 84%. Conclusion: Benign giant tumours (> 10 cm) of the breast are suitably managed by excision of the mass and a reduction mammoplasty technique of reconstruction

Management of Pipkin Type-III Femoral Head Fracture and Ipsilateral Open Floating Knee with Extensor Apparatus Injury: A Case Report.

CASE: A twenty-eight-year-old man presented with a Pipkin type-III femoral head fracture and open floating knee injury. Initially debridement was performed, during which the extensor apparatus could not be salvaged. The top priority in management of the floating knee was achievement of adequate soft-tissue coverage followed by skeletal stabilization as staged procedures. Because the femoral head was split, dislocated, comminuted, and deemed nonreconstructible, arthroplasty was considered the best option. The extensor mechanism damage was addressed by reconstruction using an iliotibial tract flap. CONCLUSION: This case report is presented for its uniqueness, the management protocol, and the difficulties encountered during the multistage treatment.

Role of Interosseous Recurrent Artery Perforators in the Posterior Interosseous Artery Flap.

The Posterior Interosseous Artery flap is a fasciocutaneous flap based on the Posterior Interosseous artery which lies invested by the fascial septum between the Extensor carpi ulnaris and Extensor Digiti Minimi where it gives off septocutaneous branches that spread out on the deep fascia to form longitudinal fascial arcades as well as supply the deep extensors. The conventional flap based on these perforators is restricted to the middle-thirds of the dorsum of forearm. Preservation of the perforators from the Interosseous Recurrent Artery by proximal ligation of the Interosseous Recurrent Artery and by protecting the index septum prolongation carrying the perforators of IRA can help us to recruit larger tissue in the flap. A total of 20 clinical cases and 10 cadaveric dissections were done to objectively define this technique.

Crystal structure of catena-poly[[cadmium(II)-di-µ2-bromido-µ2-l-proline-κ(2) O:O'] monohydrate].

In the title coordination polymer, {[CdBr2(C5H9NO2)]·H2O} n , the Cd(II) ion is coordinated by four bromido ligands and two carboxyl-ate oxygen atoms of two symmetry-related proline ligands, which exist in a zwitterionic form, in a distorted octa-hedral geometry. There is an intra-molecular N-H⋯O hydrogen bond between the amino group and the carboxyl-ate fragment. Each coordinating ligand bridges two Cd(II) atoms, thus forming polymeric chains running along the c-axis direction. The water mol-ecules of crystallization serve as donors for the weak inter-molecular O-H⋯O and O-H⋯Br hydrogen bonds that link adjacent polymeric chains, thus forming a three-dimensional structure. N-H⋯O and N-H⋯Br hydrogen bonds also occur.

Synthesis, structure, crystal growth and characterization of a novel semiorganic nonlinear optical l-proline lithium bromide monohydrate single crystal.

l-Proline lithium bromide monohydrate (LPLBM), a promising semiorganic nonlinear optical material, was synthesized and single crystals of LPLBM were grown from solution by slow evaporation technique. Single crystal X-ray structure solution reveals that the grown crystal belongs to monoclinic system with space group P21. Presence of various functional groups was identified by FT-IR and FT-Raman spectral analyses. UV-Vis-NIR spectroscopic study shows that the LPLBM crystal possesses 90% of transmittance in the range of 250-1100nm. Vickers microhardness values, the dielectric constant and dielectric loss of the LPLBM crystal were reported. Elemental analysis by energy dispersive X-ray analysis shows the presence of carbon, nitrogen, oxygen and bromine. The surface morphology of the crystal was investigated using scanning electron microscopic study. The thermal stability of the LPLBM crystal was studied from TGA and DSC analysis. Second harmonic generation efficiency of the LPLBM crystal measured by Kurtz and Perry powder technique using Nd:YAG laser is about 0.3 times that of urea.

Weil's disease presenting as atypical pneumonia.

Leptospirosis is a disease caused by spp. Leptospira, also known as Weil's disease if it manifests with jaundice. It can be associated with respiratory, renal, hepatic and haematological complications and most importantly carries a high mortality when untreated. We describe a case of a 53 year old man presenting with myalgia and fever in whom the diagnosis of leptospirosis was not initially considered. Following a deterioration in his condition a careful history revealed an apparent brief exposure to animal urine and subsequent grossly positive Leptospira serology. Treatment of his condition led to complete resolution after a brief stay on the intensive care unit. This case highlights the atypical nature of a presentation of Leptospirosis, its respiratory complications, and importance of serological testing in its diagnosis.

Fluorescence quenching and photocatalytic degradation of textile dyeing waste water by silver nanoparticles.

Silver nanoparticles (Ag NPs) of different sizes have been prepared by chemical reduction method and characterized using UV-vis spectroscopy and transmission electron microscopy (HRTEM). Fluorescence spectral analysis showed that the quenching of fluorescence of textile dyeing waste water (TDW) has been found to decrease with decrease in the size of the Ag NPs. Experimental results show that the silver nanoparticles can quench the fluorescence emission of adsorbed TDW effectively. The fluorescence interaction between Ag NPs (acceptor) and TDW (donor) confirms the Förster Resonance Energy Transfer (FRET) mechanism. Long range dipole-dipole interaction between the excited donor and ground state acceptor molecules is the dominant mechanism responsible for the energy transfer. Furthermore, photocatalytic degradation of TDW was measured spectrophotometrically by using silver as nanocatalyst under UV light illumination. The kinetic study revealed that synthesized Ag NPs was found to be effective in degrading TDW.

Anatomical study of terminal peroneal artery perforators and their clinical applications.

INTRODUCTION: Peroneal artery gives off plenty of perforators that pass through fascial septum to supply skin and tenosynovium of peroneal muscles. AIM: The aim of this study was to study the anatomical basis of perforators from terminal part of peroneal artery axiality and to make use of this knowledge in reconstructing defects of posterior heel with the advantage of reducing the morbidity of conventional flaps. MATERIALS AND METHODS: Our study was conducted at Department of Plastic surgery, Madras Medical College and Rajiv Gandhi Government General Hospital, India. We have carried out eleven cadaver dissections (from six cadavers-four fresh cadavers and two preserved cadavers) and delineated all septocutaneous and septosynovial perforators of distal peroneal axis and studied their relation with short saphenous vein (SSV) and sural nerve. Using this anatomical knowledge we have fashioned perforator based flaps in 13 patients (three propeller, four V-Y advancement, six tenosynovial flaps) for reconstruction of defects over tendo achilles and pericalcaneal region. RESULTS: In all cases, SSV and sural nerve were preserved and donor site was closed primarily. No total flap loss was noted. CONCLUSION: Perforator based flaps from distal most part of peroneal artery provide a good and reliable method for reconstruction of pericalcaneal and tendo achilles region defects with preservation of SSV and sural nerve. It also avoids contour deformity of the grafted donor site of the classical lateral calcaneal artery axial flap.

catena-Poly[[[aqua-(glycine-κO)lithium]-µ-glycine-κ(2) O:O'] bromide].

In the title coordination polymer, {[Li(C2H5NO2)2(H2O)]Br} n , the Li(+) cation is coordinated by three carboxyl-ate O atoms of zwitterionic glycine mol-ecules and by a water mol-ecule, forming a distorted tetra-hedral geometry. One of the two glycine mol-ecules bridges neighbouring complexes, forming an infinite chain parallel to the c axis. Polymeric chains are further linked by extensive hydrogen bonds involving the Br(-) anions and glycine and water mol-ecules, producing a three-dimensional network.