Versatility of the Keystone Design Perforator Island Flaps in Resurfacing Soft Tissue Defects.

Background The keystone design perforator island flap (KDPIF) is unique among local flaps because of its high potential for adaptation. We describe our experience with the use of the keystone flap for the reconstruction of a variety of defects in different regions of the body concerning its versatility, surgical outcomes, complications, postoperative pain, operative time, and esthetic outcomes. Methods A prospective observational study was conducted at our institute from June 2021 to June 2023 where the use of KDPIFs in resurfacing soft tissue defects of different etiopathogenesis was evaluated and the data were analyzed. Results Forty-four patients were included in the study with soft tissue defects of various etiologies and at different locations. The largest flap raised was 18 × 10 cm and the smallest was 4 × 2 cm. The average intraoperative time for completion of the procedure was 74.86 minutes (range: 45-120 minutes). The success rate of flap survivability was 95.45% with two patients having total flap loss necessitating another reconstructive option. Partial flap dehiscence which healed secondarily was observed in two patients. Postoperative pain showed a significant fall of 83.7% from baseline and 82.9% of cases were extremely satisfied with the esthetic outcome. Conclusion The keystone flap is a valuable reconstructive tool in the armamentarium of a plastic surgeon. It is technically reproducible, suitable to be done in resource-limited settings, and provides contiguous tissue with good vascularity and fewer complications.

Extraskeletal Ewing Sarcoma Disguised as a Vascular Malformation.

Extraskeletal Ewing sarcoma (EES) is a rare entity, accounting for only 3% of lesions encountered in upper extremity. We present two paediatric patients, who were initially diagnosed with a vascular malformation based on clinical assessment and imaging. Final histopathology revealed Ewing sarcoma of soft tissue origin, confirmed by immunohistochemical analysis. Hand surgeons, who are routinely approached for a myriad of hand pathologies, should be wary and consider EES as a differential when treating such lesions. A multidisciplinary approach with an appropriate treatment algorithm can help in a speedy diagnosis, improving the long-term prognosis of the disease. Level of Evidence: Level V (Therapeutic).

Like Father, Like Daughter - Ectodermal Dysplasia-Syndactyly Syndrome: A Case Report.

Ectodermal dysplasia-syndactyly syndrome 1 (EDSS1) is an exceedingly rare condition associated with mutations in the PVL4 gene. It is characterised by sparse, brittle hair, eyebrows and eyelashes, abnormal dentition and nails, along with bilateral cutaneous syndactyly involving the fingers and toes. We report a 2-year-old girl who presented to us with bilateral complete simple syndactyly of the third and fourth web spaces of the hands, along with bilateral syndactyly of both feet involving the second to fourth toes. Upon examination, sparse hair and eyebrows, along with abnormal dentition, were noted. Thorough clinical examination and genetic analysis were conducted on the affected child and her father, who exhibited similar clinical features. Genetic analysis revealed a homozygous nonsense mutation in the PVL4 gene in both individuals. According to the literature, EDSS1 has been reported in only 10 families worldwide, and there are no reported cases from India. Level of Evidence: Level V (Therapeutic).

Fibrolipomatous Hamartoma Over the Left Forearm and Palm.

Introduction: Fibrolipomatous hamartomas are rare congenital benign tumors that can affect the nerves. The symptoms arise due to compression and may require surgical excision. Case Report: A man in his mid-20s suffered swelling over the volar aspect of the left forearm and hand for 4 months. He was symptomatic. A soft, non-tender swelling of size 6 × 4 cm was present over the flexor aspect of the left forearm and palm, with features suggestive of median nerve compression. Magnetic resonance imaging and electromyography were performed. Decompression of the carpal tunnel was performed with debulking of fibrofatty elements and fine dissection of the neural elements. Conclusion: This case report demonstrates a rare fibrolipomatous hamartoma encompassing the median nerve, which required surgical excision.

Adherent Polyurethane Foam Following VAC Dressing: A Rare Complication.

Introduction: Vacuum-assisted closure (VAC) dressings are used for many indications nowadays in wound management. However, there are complications with VAC dressings also. In this study, we report a 44-year-old patient with a vertical shear injury with post-operative wound complication of adherent polyurethane sponge over her wound which was removed by piecemeal dissection. Case Report: A 44-year-old patient sustained a vertical shear pelvic injury following which spinopelvic fusion surgery was performed. The patient developed wound dehiscence along with discharge on POD 4. Following this, VAC dressing was applied to the wound. After 3 days, the polyurethane sponge became adherent to the wound. The sponge was removed gradually through daily debridement in a piecemeal manner. The wound was found to be healthy and a keystone flap was raised to cover the wound. Conclusion: Although such complication of an adherent sponge has not been reported to date, one must keep in mind this complication while making improvisations to commercially available VAC dressings.

Tuberculous flexor tenosynovitis of wrist and hand.

A woman in her 40s presented with a swelling over her left distal forearm and hand since 7 months, progressively increasing in size. She had history of difficulty in moving her wrist and fingers with no associated pain. She had no immune or chronic conditions except for hypothyroidism for which she was on regular medication. On examination, there was an 8×7 cm swelling on the radial side of the volar surface of her left distal forearm extending till the thenar eminence. MRI of the left upper limb was suggestive of a soft tissue swelling arising from the flexor tendon.The patient was planned for surgical excision of the swelling. Intraoperatively, there was a mass arising from the flexor tendons of flexor digitorum superficialis, flexor digitorum profundus (FDP) and flexor pollicis longus (FPL), extending distally up to the mid palm region. On incising the flexor tendon sheath, it was observed that multiple yellowish rice like granules extended across the tendons. The lesion was excised completely and sent for histopathology examination. The lax FDP of little and ring fingers were plicated following proper tension adjustment and defect in FPL was primarily repaired. Postoperatively, the patient recovered well with no local wound complications. The biopsy report was suggestive of tuberculosis. The patient completed a course of antituberculosis treatment in 6 months.

The "Lost" Peroneal Vessel - A Rare Anatomical Variation in Free Fibula Flap Harvest.

Introduction: Vascularized free fibula flap is one of the commonly used flaps in autologous soft-tissue and osseous reconstructions in the modern era. While there is abundant literature available on the variable branching pattern and course of the popliteal artery, tibial arteries, and dorsalis pedis artery, there is a paucity of text available on the not-so-common peroneal vessels. Case Report: A case of a 60-year-old male who was diagnosed with carcinoma of buccal mucosa with involvement of the mandible of the right side was planned for wide local excision with modified radical neck dissection and resurfacing of the resultant defect using a contralateral free fibula osseocutaneous free flap. Intraoperatively, the peroneal vessels were noted to have a premature termination along the lateral border of distal one-third of the fibula, after giving a communicating branch to an anterior tibial artery. The flap was raised based on the same pedicle, without ligating any distal portion of the vessel. Reconstruction of the defect and post-operative recovery was uneventful. Full flap survival was observed. Conclusion: We report this case as this vascular "anomaly" is one of its kind and has been oblivious to the literature and practicing microsurgeons globally.

Versatility of Medial Sural Artery Islanded Pedicled Perforator Flap for Resurfacing Areas Around the Knee.

ABSTRACT: Soft tissue defects with exposed tendon, bones, and joints around the knee are difficult and challenging to treat because of its location over a joint, requires a stable cover that is supple and stretchable. For any knee defects, the gastrocnemius muscle flap is the first choice for the reconstruction, although it causes less functional deficit; however, because of its less reach, it is difficult to cover the defect in the superolateral aspect of knee joint and anterior to the tibial tuberosity with the other disadvantage being the bulkiness. The medial sural artery perforator flap (MSAPF) provides thin fasciocutaneous tissue similar to the adjacent normal soft tissue in the knee and so, its use leads to an improved reconstruction of contour and eliminating the need of a skin graft over the primary defect. Here, we will be discussing a case series using MSAPF to cover the defects around the knee.

Aesthetic Outcome of Gynecomastia Management with Conventional Liposuction and Cross-Chest Liposuction: A Prospective Comparative Study.

BACKGROUND: Liposuction is the most accepted technique for treatment of gynecomastia at present with or without residual gland tissue excision. Conventional liposuction uses incisions for introduction of cannula, made usually at the inframammary crease or axilla resulting in consequent scars. Cross-chest liposuction technique was introduced to avoid these additional scars and improve the aesthetic outcome. This study aimed to evaluate the difference between aesthetic outcome of conventional liposuction and cross-chest liposuction in treatment of gynecomastia. METHOD: A prospective comparative study between 2 groups with 15 patients in each was conducted, one with conventional and the other cross-chest liposuction. Excision of residual gland tissue was performed through circum-areolar incision in both the groups. Aesthetic outcome was evaluated in both the groups using Likert scale and compared. RESULT: The mean age of the patients was 22.6 years and the mean duration of presentation was 8.13 years. Satisfaction rate with conventional and cross-chest liposuction was 80% and 86%, respectively, as assessed by the patients. The rate was 80% and 77%, respectively, in both the groups as assessed by independent observer. The complication rate was 13.3% in conventional and 20% in cross-chest group. The difference in outcome was not statistically significant between two groups. Difference between the mean Likert scores of pre-operative and post-operative satisfaction was statistically significant for both the techniques. CONCLUSION: The conventional and the cross-chest liposuction, both yield comparable results when used for treatment of gynecomastia in terms of aesthetic outcome. 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.