Revisiting Elliot's Modification of Moberg's Flap and Our Improvisation.

Thumb tip injuries constitute one of the most common hand injuries. There are various reconstructive options for thumb tip injuries. We present our series of thumb tip injuries reconstructed using Elliot's modification of the Moberg flap, which provides like-for-like tissue. We also present our flap improvisation, which can be useful in the armamentarium of plastic surgeons. Background Moberg described the advancement flap for thumb defects in 1964, which was modified by O'Brien in which the proximal part of the flap is incised and advanced. Although it is a popular flap, it has the disadvantage of interphalangeal (IP) joint flexion deformity. Among the various modifications of the Moberg flap, Elliot's flap provided more tissue with minimal donor site morbidity and no usage of skin grafts or first web skin. Methods We retrospectively analyzed the patients who underwent reconstruction of thumb defects by Elliot's modified Moberg's flap. The size of the defect, etiology, and IP joint movement were analyzed. Two patients underwent our improvised flap where a daughter flap was elevated within Elliot's flap. Results Between January 2021 and September 2023, 12 patients underwent reconstruction by Elliot's flap. All flaps settled well. There was no IP joint deformity. Two patients had scar hypertrophy that was managed conservatively. Conclusion Elliot's modification of the Moberg flap is a very useful but underutilized flap for thumb tip injuries that provides like tissue with sensation and with little donor site morbidity. It can be used for thumb tip defects of up to 3 cm . It is possible to incorporate a second V-Y flap in patients for whom additional movement is required for tension-free closure.

Applications and Reliability of Dorsal Metacarpal Artery Perforator Flap.

Dorsal metacarpal artery perforator flap (DMAP), first described by Quaba and Davison, is a useful tool in the armamentarium of plastic surgeons. It provides like for like tissue for the reconstruction of dorsal finger defects. It is a simple and relatively easy flap to harvest with minimal donor site morbidity. In this case series, we present our experience, applications, and surgical technique of flap harvesting.

Assessing the Accuracy of Common Clinical Tests for Detecting Palmaris Longus: A Prospective Study in a Tertiary Center.

Background Palmaris longus (PL) is a short-bellied muscle with a long tendon that merges with the palmar aponeurosis. It is supplied by the median nerve and acts as a tensor of the palmar aponeurosis and flexes the wrist. This tendon is commonly used for tendon transfers and as a donor for tendon graft. There are numerous clinical tests to detect the presence of PL like Schaeffer's test, Thompson's test, Mishra's test I, Mishra's test II, Pushpakumar's "two-finger sign" method, and AIIMS test. The principle of all these tests is to make the tendon prominent by eliciting its flexor action and then its identification by inspection and palpation. Objectives The tests that are consistently easy to perform with good understandability would be easy to explain to the general population (patients). The aim of our study is to find out the accuracy and easy comprehensibility of various tests using compulsive postures for detecting PL tendon clinically. Materials and Methods This is a prospective study on 137 participants. All the patients were subjected to six clinical tests to detect the presence or absence of PL tendon. The results were recorded for both hands by a single observer. Results Of the 137 participants, 75 were males (54.74%) and 62 were females (45.26%). The mean age was 21 years. The AIIMS test showed the maximum number of tendons, that is, 113 (82.4%) in the right hand and 108 (78.8%) in the left hand. In view of the ability to comprehend the tests, 119 (86.9%) subjects understood Schaeffer's test very easily. Conclusion According to this study, the AIIMS test best demonstrates the PL tendon, and Schaeffer's test was the test most easily understood by the subjects.

Feasibility of Laterocaudal Approach in Comparison with Subtarsal Approach in the Management of Orbital Rim Fractures in Indian Population: A Prospective Study.

A balance between surgical access and aesthetics, with lesser post-op sequelae, is inevitable in the management of facial fractures. Even though various approaches are widely practised, further modifications and revisions are encouraged for better outcomes. We performed a prospective cross-sectional study on 30 patients with Zygomatico-Maxillary Complex (ZMC) fracture with inferior orbital rim involvement. Surgical management was performed using subtarsal (Group A) or laterocaudal (Group B) approach, during which the time taken to expose fracture and the ease of access was documented. Scar evaluation was performed using SCAR Scale on the 15th day and after one-month and three-month follow-up, and the post-op complications including ectropion, infections, edema, etc., were documented. There was a significant reduction in the time taken (p < 0.001) in group B than in group A. The ease of access did not demonstrate any significant difference. The SCAR scale score was significantly reduced at 3rd-month follow-up in group B compared to the other group (p = 0.009). Laterocaudal approach demonstrated lesser time-taken and better access to the inferolateral rim, with superior aesthetics and fewer complications. This approach can be employed in clinical practice, especially with inferolateral rim involvement in ZMC fractures.

"Like For Like" Reconstruction of Heel Pad with Medial Plantar Artery Flap-Functional and Aesthetic Outcomes in A Series of 19 Cases.

Heel pad loss can cause serious problems in weight-bearing and locomotion. The medial plantar artery (MPA) flap is a suitable "like for like" replacement. Nineteen patients whose heels were reconstructed with MPA flap between July 2015 and February 2020 were studied. All patients were assessed based on flap survival, functionality, and patient satisfaction. Loss of heel pad was due to diabetic ulcer (11), trauma (6), tumor (1), and unstable scar (1). The largest flap measured 9 × 7 cm. Sixteen flaps were done as fasciocutaneous flaps and three in combination with abductor hallucis muscle (AbdH). All the flaps survived. The average functional scores at 6, 12, 18, and 24 months were 86.86, 89.62, 89.38 and 97.33 based on AOSAS-AH score. Average patients' satisfaction was 8.7/10. To conclude, the MPA system is a versatile vascular axis providing "like for like" tissue for heel pad reconstruction which is reliable and durable.

Traditional Versus Virtual Surgery Planning of the Fronto-Orbital Unit in Anterior Cranial Vault Remodeling Surgery.

BACKGROUND: Craniosynostosis correction surgery is a complex procedure, which involves complete dismantling and reassembly of the cranial vault components. The traditional planning method for these surgeries results in increased intra-operative time owing to its highly subjective nature. The advent of virtual surgical planning (VSP) platform has lead to a greater pre-operative insight and precision outcome in calvarial remodeling surgeries. The purpose of this paper is to evaluate intra-operative time and blood loss difference as a measure of surgical efficiency between VSP based template guided Anterior Cranial Vault Reconstruction (ACVR) with Fronto-Orbital Unit Advancement (FOUA) and the traditional surgeries. METHODS: Data were collected from patients who underwent ACVR with FOUA in our unit. Patients were divided into 2 groups, Template Fronto-Orbital Unit (TFOU) group and Non-template Fronto-Orbital Unit (NFOU) group. In TFOU group, Virtual planning along with fabrication of Template guide was carried out. Patients undergoing ACVR using traditional techniques were categorized as NFOU group. A comparative prospective analysis was carried out in terms of Intra-operative time duration and blood loss. Student 't' test was used to compare the means of the 2 groups. RESULTS: A total of 10 patients were included in the present study. There were 5 control (NFOU) and 5 TFOU cases. There was a significant decrease in the operating time in TFOU group compared to the NFOU group. TFOU group also showed reduced intra-operative bleed compared to the NFOU group. CONCLUSION: Virtual surgical planning (VSP) and 3D modeling with prefabricated template guide augurs reliable outcomes and portends the possibility of lesser intra-operative time. It is a valuable tool, which offers enormous benefits in terms of precise pre-surgical planning with predictive results.

Chimeric Anterolateral Thigh Flap for Primary Functional Reconstruction of Complex, Composite Near Total Hemi Facial Post Excision Defects.

INTRODUCTION: Microvascular free tissue transfer has revolutionized the management of complex composite head and neck defects. AIM: To evaluate the functional and aesthetic outcomes in the primary reconstruction of post-excisional near total hemifacial defects with the chimeric anterolateral thigh flaps (cALT). MATERIALS AND METHODS: The author as a prelude to this clinical study has done a cadaveric study on the quadriceps artery angiosome. In this retrospective cohort study, data are collected from the records of 6 patients who had undergone primary cALT flap reconstruction for their post excisional near total hemifacial defects from January 2013 to December 2017. All 6 patients with various advanced malignancies involving the hemiface underwent wide local excision. Wide local excision resulted in the loss of skin and critical facial muscles that led to near total hemiface composite defects. Reconstructions were done with the cALT flaps that included segment of the vastus lateralis muscle harvested on its independent neurovascular perforator pedicle and the skin paddle on a separate perforator. In all cases, the facial nerve stumps were anastomosed to the nerve to vastus lateralis for reanimation of the face. In addition, 4 patients underwent primary radical neck dissection, but all had postoperative radiotherapy and chemotherapy. RESULTS: All patients attained well-pronounced nasolabial fold, symmetrical smile, and good oral competence in an average period of 10.75 months post operatively. In an average of 22 months follow up, none of them had locoregional recurrences. None required any secondary procedures. CONCLUSION: In the post excisional near total hemifacial composite defects, primary functional reconstruction with tailored cALT flaps can bring good aesthetic and functional results.

Primary Paraspinal Hydatidosis Causing Acute Paraplegia.

The zoonotic infection hydatidosis is caused by the tapeworm cestode, Echinococcus granulosus. Though considered endemic in India where association of humans with sheep and dogs form part of the livelihood, primary skeletal muscle involvement of the disease is an extremely rare event. We report a case of primary paraspinal hydatidosis with extradural extension causing acute paraplegia. Excision of the cyst and decompression of the cord was done along with albendazole therapy. Paraspinal hydatid disease is a rare entity, and in regions where hydatid disease is endemic, it can be involved in the differential diagnosis of acute compressive myelopathy. Although antihelminthic chemotherapy forms the mainstay of the treatment, surgical intervention forms a major part of the management.