Donor Finger Morbidity in Cross-Finger Flap: A Systematic Review and Meta-Analysis.

Background The morbidity of donor finger in a cross-finger flap has not received as much importance as the outcomes of the flap itself. The sensory, functional, and aesthetic morbidity of donor fingers, reported by various authors, are often contradictory to each other. In this study, objective parameters for the sensory recovery, stiffness, cold intolerance, cosmetic outcome, and other complications in the donor fingers, reported in the previous studies, are systematically evaluated. Methods This systematic review is reported using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol and was registered with the International prospective register of systematic reviews (PROSPERO registration no. CRD42020213721). Literature search was done using "cross-finger," "heterodigital," "donor finger," and "transdigital" words. Data regarding demography, patients' number and age, follow-up duration and outcomes of donor finger, including 2-point discrimination, range of motion (ROM), cold intolerance, questionnaires, etc. were extracted from included studies. Meta-analysis was performed using MetaXL and risk of bias was evaluated using Cochrane risk of bias tool. Results Out of the total 16 included studies, 279 patients were objectively evaluated for donor finger morbidity. Middle finger was most frequently used as donor. Static two-point discrimination seemed to be impaired in donor finger in comparison to contralateral finger. Meta-analysis of ROM suggested that statistically there is no significant difference in ROM of interphalangeal joints in donor and control fingers (pooled weighted mean difference: -12.10; 95% confidence interval: -28.59, 4.39; I2 = 81%, n = 6 studies). One-third of donor fingers had cold intolerance. Conclusion There is no significant effect on ROM of donor finger. However, the impairment that seems to be in sensory recovery and aesthetic outcomes needs to be further evaluated objectively.

Difference between Capillary Blood Glucose of Free Flap and the Patient: A Novel Objective Marker of Free Flap Vascular Compromise during Postoperative Monitoring.

Background Defining cut-off values of flap glucose levels in diagnosing free flap vascular compromise, without taking patients' glucose levels into account, does not hold good in all circumstances, especially in cases of high fluctuations in patients' capillary blood glucose and in diabetic patients. The aim of our study was to establish the role of capillary blood glucose measurements of the flap in relation to patients' fingertip, as an objective tool for postoperative free flap monitoring. Methods A total of 76 free flaps underwent postoperative monitoring with reference test (clinical parameters) and simultaneously with our index test (difference between capillary blood glucose of free flap and the patient), in non-diabetic and diabetic patients. Patients' demography and flap characteristics were also recorded. An ROC curve was plotted to determine diagnostic accuracy and cut-offs of the index test in diagnosing free flap vascular compromise. Results Our Index test has a cut-off value of 24.5 mg/dL with 68.75% sensitivity and 93% specificity, with an accuracy of 91.54%. Conclusion The difference between capillary blood glucose of free flap and the patient is simple, feasible, and inexpensive, and can be done by any health care professional and does not require any specialized facilities or training. It has an excellent diagnostic accuracy to detect impending free flap vascular compromise, especially in non-diabetics. Although in diabetics, this test becomes less accurate. Being an observer-independent objective test, the difference in capillary blood glucose of patient and flap measurement can be used as a highly reliable tool for postoperative free flap monitoring.

Effectiveness of Nasolabial Flap Versus Paramedian Forehead Flap for Nasal Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Different studies performed on nasal subunit reconstruction by either the nasolabial flap or the paramedian forehead flap have reported contradictory outcomes and complications, claiming one flap or the other as superior. This inconsistency has led to a gap in existing literature regarding the preferable flap for nasal reconstruction. Our aim was to statistically evaluate and compare these two flaps for nasal reconstruction, in terms of subunit preference, complications, and outcomes, using data from previous studies. METHODS: This systematic review is reported using PRISMA protocol and was registered with the International prospective register of systematic reviews. The literature search was done using "paramedian forehead flap", "nasolabial flap", "melolabial flap", "nasal reconstruction". Data regarding demography of study and population, subunit reconstructed, complications, and aesthetic outcomes were extracted. Meta-analysis was performed using MetaXL and summary of findings using GRADEpro GDT. RESULTS: Thirty-eight studies were included, and data from 2036 followed-up patients were extracted for the review. Meta-analysis was done on data from nine studies. Difference in alar reconstruction by forehead versus nasolabial flap is statistically significant [pooled odds ratio (OR) 0.3; 95% CI 0.01, 0.92; p = 0.72; I2 = 0%, n = 6 studies], while for dorsum and columella reconstruction the difference is not statistically significant. Risk of alar notching is marginally more in forehead flap, however difference in incidence of partial/complete flap necrosis, alar notching and hematoma/bleeding among the flaps is not statistically significant. CONCLUSION: Alar reconstruction is preferred by nasolabial flap. Complications are similar in both groups. Comparison of aesthetic outcome needs further exploration. 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 .

Nonvenomous Snakebite in Pediatric Age Group-Wolf under a Sheep's Coat.

Nonvenomous snakebite, far outnumbering venomous bites, is a neglected occupational hazard in the Indian subcontinent. We encountered four cases of traditionally nonvenomous snakebite in pediatric age group with symptoms of limb swelling proximal to the bite site. All cases were found to have extensive fibrinous exudate and fibrinoid necrosis of the deeper layer of fat, deep to the intact skin and superficial layer of fat, extending far from the wound toward the proximal limb in continuity. This obscured presentation of infection and extensive necrosis of only the deeper layer of fat warrants exploratory incisions proximally for thorough debridement, underlying the normal appearing skin.

Expanded Paramedian Forehead Flap for Nasal Reconstruction Following Congenital Nevus Excision.

In this report, we discuss the excision of a large congenital nevus covering the nose and face and the reconstruction of the defect using an expanded forehead flap, in a 24-year-old man. We observed that after incorporating specific modifications including tissue expansion, thinning of the distal part of the flap, and placing the pedicle over the cutaneous branch of the supratrochlear artery, we were able to provide excellent aesthetic results using this time-tested paramedian forehead flap for nasal reconstruction. After we inset the flap, there was negligible donor site morbidity during a 33-month follow-up period.

A Simple, Atraumatic Technique for Tendon Retrieval and Holding During Tendon Repair.

In this report, we describe an atraumatic technique that can be used intraoperatively to hold and retrieve tendons during tendon repair procedures. To use this technique, the surgeon transfixes a 24-gauge needle 1.5-3.5 cm from the cut ends of the tendon and then uses a Kocher artery curved forceps to loop the end of the needle upon itself up to 180°. The surgeon can then use the needle to retrieve or hold the tendon during the repair. This simple, low-cost technique can be very effective and efficient when used in primary care centers, emergency departments, or other treatment areas.

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.

A Prospective Trial Comparing Outcomes at 11 Months of a Standard Cross-Finger Flap versus a Laterally Based Thenar Flap for Fingertip Reconstruction.

Background: The standard cross-finger flap (CFF) and laterally based thenar flap (LTF) are the time-tested modalities of fingertip reconstruction. We were unable to find any studies that have compared these two flaps for fingertip reconstruction. The aim of this study is compare the outcomes of these two flaps at 11 months after fingertip reconstruction. Methods: This is a prospective study of 40 patients with fingertip amputation who underwent reconstruction with either a standard CFF or an LTF. Data with regards to the patient, the injury, treatment and complications were recorded. Patients were followed up weekly for the first 6 weeks and at 3, 6, 9 and 12 months thereafter. Outcome measures assessed at final follow-up included passive range of motion, two-point discrimination, cold intolerance, patient aesthetic satisfaction with the flap, assessment of donor scar and psychosocial benefit. Results: Fingertip reconstruction was done with 23 CFFs and 17 thenar flaps. Partial necrosis was noted in three thenar flaps. The mean follow-up period was 11 months. The sensory recovery and aesthetic satisfaction with the flap were greater in thenar flap group. There were no differences between the two flaps in the other outcome measures. Conclusions: Sensory recovery and aesthetic outcomes were better in thenar flaps compared to a CFF. However, thenar flap were associated with a greater incidence of partial flap loss. Level of Evidence: Level III (Therapeutic).

Fingertip Amputation Reconstruction with VY Advancement Flap: Literature Review and Comparative Analysis of Atasoy and Kutler Flaps.

BACKGROUND: Many different flaps had been described to cover exposed bone in fingertip amputations and injuries. The variants of VY advancement flap, by far the simplest, had proven to render good functional and aesthetic outcome. We aimed to revisit and compare the various VY advancement flaps in fingertip reconstruction. METHODS: PubMed [MEDLINE] database was searched for VY advancement flap in fingertip reconstruction. Demographic and outcome data were extracted from relevant studies and comparative analysis was made. Patients with fingertip amputations undergoing reconstruction by either Kutler of Atasoy flaps in our institute, were assessed for sensory recovery, cold intolerance, joint's range of motion, and aesthetic outcomes and results were analysed. RESULTS: Among the 744 articles, 32 citations went full text review and were included, while data of 13 articles were tabulated. Weighted mean of 2PD in Kutler and Atasoy estimated to be 6 and 7.5 mm respectively. Hook nail deformity was in 29% and 35%, pain was present in 71% and 30% patients, in Kutler and Atasoy flaps respectively. Forty fingertips with Allen type II/III were reconstructed. Sensory outcomes of Atasoy flap and Kutler flaps were better than the previous study results. Four patients had cold intolerance. All patients achieved satisfactory aesthetic outcome. CONCLUSION: Over time, VY advancement flap have been successfully used for reconstruction of Allen type II-IV fingertip amputations, as suggested by the good sensory, functional and aesthetic outcomes.

Reconstruction of a Large Traumatic Medial Cheek Defect Using an Anterior-Based Subcutaneous Cervicofacial Rotation Advancement Flap.

In this article, we describe reconstruction of a large left-side medial cheek defect in a 78-year-old woman using a cervicofacial rotation advancement flap. To our knowledge, this is the second case of reconstruction of a large traumatic medial cheek defect using an anterior-based subcutaneous cervicofacial rotation advancement flap that has ever been reported. We applied retention sutures at the level of the jawline and zygomatic eminence using 3-0 nonabsorbable sutures between the subcutaneous tissue of the flap and the periosteum. Despite the limitation of having partially injured adjacent tissue available for reconstruction, meticulous dissection together with skilled postoperative nursing care yielded a good aesthetic outcome in this case.

Plastic surgery practices amidst global COVID-19 pandemic: Indian consensus.

INTRODUCTION: The COVID-19 pandemic having spread globally has profound implications on medical and surgical care, which is given by the health care providers. At this time, though there are guidelines and recommendations for medical management of these patients, there is a lack of guidance on how a plastic surgeon should approach the COVID-19 suspect or infected patient who presents either in an elective or emergency setting. We aim to provide a consensus guideline based on the current recommendations of the Indian Council of Medical Research (ICMR) and the pooled experience of the major centers performing plastic and reconstructive surgery in India. METHODS: The current guidelines and recommendations on the COVID-19 pandemic were studied from both government and nongovernment sources including ICMR. The problems in the specialty of plastic surgery were categorized into four groups and for each group, separate and individual guidelines have been formulated. GUIDELINES: Consensus guidelines have been formulated for the specialty of Plastic and Reconstructive surgery. The patients requiring plastic surgery service have been categorized into four groups of acute, subacute, chronic, and late category. Acute cases are the ones who require intervention within 24-48 h. Subacute cases are the ones who require intervention in the next 3-10 days, while the chronic are the ones who need plastic surgery preferably within a month. The late category are the ones who need surgery within the next six months. This has been done based on the urgency and priority of surgical intervention titrated against the risks of operating and inadvertently acquiring the exposure of COVID-19-positive patients. CONCLUSION: Currently, in the wake of COVID-19 pandemic, there are no clear guidelines specific to the vast majority of patients who come for a plastic surgery intervention. This puts the patients at risk due to the impending plastic surgery problem while at the same time it poses a risk of exposure to COVID-19 for the surgical team. Consensus guidelines are presented, to steer the plastic surgeon in his work, in the wake of COVID-19 crisis. The guidelines are based on firm scientific evidence from the reputed research and regulatory bodies and have been made in consonance with plastic surgery experts around the country, so that these practices best suit the needs of the patients, while being mindful of resource limitations and infection risks. The approach of "delayed conservative treatment" works best in the present case scenario.

Finger pulp reconstruction with thenar flap: Aesthetic and functional outcome.

PURPOSE: Fingertip injuries are common in industrial production activities as well as in domestic work. Loss of pulp hampers daily life activities. Functional and aesthetic aspects are important in fingertip reconstruction. The bone is usually exposed along with soft tissue loss. Therefore to reconstruct the pulp flap with adequate bulk is required. METHODS: We reported a case series of 12 patients with the injury over the volar aspect of distal phalanx of the index or middle finger. In all cases, laterally based thenar flap was chosen. The flap donor site was closed primarily in most of cases, while 4 patients required skin graft. The flap was detached between 2-3 weeks. Functional assessment was done using static and dynamic 2-point discrimination and range of motion at each joint. The aesthetic outcome was assessed through questionnaire. The results were analyzed using the unpaired t-test (SPSS version 21). RESULTS: Partial necrosis occurred in 2 cases while rest of flaps survived successfully. Static 2-point discrimination ranged from 6-10 mm, mean 8.6 mm; and dynamic 2-point discrimination ranged from 8-10 mm, mean 8.9 mm. The mean satisfaction score was (4.0 ± 0.55). CONCLUSION: Thenar flap is a good choice for reconstruction of the finger pulp as it provides the bulk with good functional and aesthetic outcome.

Bilateral congenital aplasia of nasal lower lateral cartilage: a rare anomaly.

Congenital nasal anomalies are rare and occur in 1/20 000-1/40 000 newborns. An 8-year-old boy presented with developmental aplasia of bilateral nasal lower lateral cartilages, with excessive wrinkled and loose skin on the dorsum of the nose and with difficulty breathing through the nose. This is probably the first such case to be reported in the literature. The defect was reconstructed using conchal and septal cartilage grafting through an external rhinoplasty approach. At the end of the 12-month follow-up period, the patient was found to be satisfied with the functional and aesthetic results of the operation. Bilateral congenital aplasia of nasal lower lateral cartilages is extremely rare. Paediatric rhinoplasty is imperative in such cases.

Holistic Care Approach for the Effective Management of Severe Radiation Dermatitis Using Neem (Azadirachta indica) and Honey after Head-and-Neck Radiotherapy.

Head and neck cancer is the eighth common type among all cancer types around the world. Its treatment comprises surgery, radiation therapy, chemotherapy and /or a combination of restoration therapy and social support Conventional fraction size ranges from 1.8 to 3 Grays (Gy) per fraction over 4-6 weeks. The accumulative dose of radiation for the primary treatment of head and neck cancer treatment is 60 to 70 Gy, depending on the irradiation of the tumor. Ionizing Radiotherapy is used along with concurrent chemotherapy which is the standard treatment in locally advanced head and neck cancers. Radiation treatment is commonly delivered in the form of high energy photons through an external beam. These results in ionization of electrons that cause direct strand breaks of cellular DNA and the release of free radicals, resulting in cellular damage to both normal and tumor cells. Radiation disrupts the normal process of wound healing at various stages.

Two-staged reverse sural flap: a versatile flap with consistent results in the soft tissue reconstruction of distal leg and heel defects-an institutional experience.

BACKGROUND: Reverse sural flap (RSF) is commonly used for soft tissue reconstruction of distal leg and heel defects. The classic method of flap transfer is the single-staged cutaneous islanded reverse sural flap (SS-RSF). This method is associated with variable flap complications notably the venous congestion. The other form of flap transfer is the two-stage reverse sural flap (TS-RSF), in which the pedicle of the flap is exteriorized in the first stage. Flap division and re-inset are done in the second stage. The aim of this paper is to review the flap outcomes and complications among the SS-RSF and TS-RSF reconstruction of soft tissue defects in the distal leg and heel. METHODS: This is a retrospective chart review of RSF being operated in a tertiary care hospital. The duration of study was 1.5 years. Twelve RSFs (6 SS-RSF, 6 TS-RSF) were done for soft tissue defects in the distal leg and heel. Wounds of various etiologies (traumatic, chronic, non-healing ulcers) were reviewed. Trauma was the most common etiology with 8 out of 12 (66.7%) patients. Large wounds, donor site damage and patients with peripheral vascular disease were excluded from the study. RESULTS: Five out of six (83.3%) of TS-RSF healed uneventfully. However, 3 out of 6 (50%) of SS-RSF had partial flap necrosis. All complicated flaps healed well subsequently. No donor site complication was found in any of our patients. CONCLUSION: Pedicle exteriorization in TS-RSF eliminates the element of venous congestion and eventually flaps necrosis. Less technical expertise and minimal morbidity are additional advantages of TS-RSF. LEVEL OF EVIDENCE: Level IV, therapeutic study.

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.

Tracing overlapping biological signals in mid-infrared using colonic tissues as a model system.

AIM: To understand the interference of carbohydrates absorbance in nucleic acids signals during diagnosis of malignancy using Fourier transform infrared (FTIR) spectroscopy. METHODS: We used formalin fixed paraffin embedded colonic tissues to obtain infrared (IR) spectra in the mid IR region using a bruker II IR microscope with a facility for varying the measurement area by varying the aperture available. Following this procedure we could measure different regions of the crypt circles containing different biochemicals. Crypts from 18 patients were measured. Circular crypts with a maximum diameter of 120 µm and a lumen of about 30 µm were selected for uniformity. The spectral data was analyzed using conventional and advanced computational methods. RESULTS: Among the various components that are observed to contribute to the diagnostic capabilities of FTIR, the carbohydrates and nucleic acids are prominent. However there are intrinsic difficulties in the diagnostic capabilities due to the overlap of major absorbance bands of nucleic acids, carbohydrates and phospholipids in the mid-IR region. The result demonstrates colonic tissues as a biological system suitable for studying interference of carbohydrates and nucleic acids under ex vivo conditions. Among the diagnostic parameters that are affected by the absorbance from nucleic acids is the RNA/DNA ratio, dependent on absorbance at 1121 cm-1 and 1020 cm-1 that is used to classify the normal and cancerous tissues especially during FTIR based diagnosis of colonic malignancies. The signals of the nucleic acids and the ratio (RNA/DNA) are likely increased due to disappearance of interfering components like carbohydrates and phosphates along with an increase in amount of RNA. CONCLUSION: The present work, proposes one mechanism for the observed changes in the nucleic acid absorbance in mid-IR during disease progression (carcinogenesis).

Pre-screening and follow-up of childhood acute leukemia using biochemical infrared analysis of peripheral blood mononuclear cells.

BACKGROUND: Recent advances in chemotherapeutic treatment of childhood acute leukemia have improved remission rates to about 80%. With the development of novel drugs and treatment protocols adapted for specific individual patients, a simple diagnostic tool for following patients' responses on a daily basis is required. In the present clinical study, we have investigated the usefulness of Fourier transform infrared microscopy (FTIR-MSP) for pre-screening and follow-up of leukemia patients undergoing chemotherapy. METHODS: Blood samples were collected from leukemia patients before and during treatment as well as from patients with high fever and healthy subjects which served as control groups. Peripheral blood mononuclear cells (PBMCs) were isolated and their spectra obtained using FTIR-MSP. The presence of blasts in bone marrow and other diagnostic and prognostic clinical parameters were determined during follow-up up to 1000 days. RESULTS: Leukemia was efficiently indicated by a reduced lipids and elevated DNA absorption of PBMC together with additional characteristic spectral bands. These diagnostic markers were used for monitoring the biochemical changes in PBMCs during chemotherapy. The trends of several markers were found to be in agreement with blast percentage as determined by flow cytometry. CONCLUSIONS: Our findings reveal the utility of FTIR-MSP for leukemia pre-screening independently of symptoms common to leukemia. Furthermore, FTIR-MSP supplies precursor indication regarding patient response to treatment compared to current methods. GENERAL SIGNIFICANCE: This preliminary study shows a great potential of FTIR-MSP as a complementary tool for childhood leukemia pre-screening and follow-up which may allow faster response to critical problems arise during treatment.

Fluorescence spectroscopy of H-ras transfected murine fibroblasts: a comparison with Monte Carlo simulations.

Autofluorescence properties of tissues have been widely used to diagnose various types of malignancies. In this study, we measured the autofluorescence properties of H-ras transfected murine fibroblasts and the counterpart control cells. The pair of cells is genetically identical except for the transfected H-ras gene. We applied Monte Carlo simulations to evaluate the relative contributions of Rayleigh and Mie scattering effects towards fluorescence in an in vitro model system of normal and H-ras transfected fibroblasts. The experimental results showed that fluorescence emission intensity was higher for normal cells than the malignant counterpart cells by about 30%. In normal cells, linearity in emission intensity was observed for cell densities of up to 1.0 x 10(6) cells/ml whereas for transformed cells it was up to 1.4 x 10(6) cells/ml. Nuclear volume changes give good account for the differences in the intrinsic fluorescence between normal and malignant cells. The Monte Carlo (MC) code, newly developed for this study, explains both predominant experimental features: the large fluorescence intensity differences between the transfected and the corresponding control cells as well as the phenomena of the red shift in the excitation spectra as a function of cell density. The contribution of Rayleigh scattering was found to be predominant compared to Mie scattering.