Pedicled anterolateral thigh flap: A versatile flap for complex regional defect reconstruction.

Objectives: Soft-tissue defects of the lower abdomen, perineum, groin, and trochanteric area often involve the loss of composite tissue components and are technically challenging to reconstruct. The goals of reconstruction should include the replacement of the defect with a suitable soft-tissue flap that provides stable coverage while protecting important exposed structures. However, there are limited locations in this region for the creation of pedicled flaps for complex defect reconstruction. The pedicled anterolateral thigh (ALT) flap is considered superior to other comparable flaps due to its varying soft-tissue components and long pedicle with consistent anatomy that allow the reconstruction of locations that are difficult to reach without significant flap donor site morbidity. Herein, we present a case series of our experience of using a pedicled ALT flap to reconstruct regional defects over a range of locations. Methods: The present study comprised ten patients who underwent surgical reconstruction of soft-tissue defects of the lower abdomen, groin, trochanteric, scrotal, and penoscrotal defects using a pedicled ALT flap over a two-year period. The flap was customized according to the defect when required. Results: In our case series, flap loss was not observed with only a few minor complications. All patients accepted the aesthetic appearance of the flap recipient site area without requesting revision surgery. The donor site was closed primarily in half of all cases, with split skin grafting applied in the remaining patients. Graft take at the flap donor site was satisfactory in all cases. Conclusion: A pedicled ALT flap is a reliable and suitable option for complex soft-tissue reconstruction for regional soft-tissue defects of the lower abdomen and perineum.

Complicated Facial Lacerations: Challenges in the Repair and Management of Complications by a Facial Trauma Team.

Study Design: This is a descriptive study where we present our experience in managing complicated facial wounds over a period of 1 year at a level 1 trauma centre by a dedicated facial trauma team consisting of a plastic surgeon, a trauma surgeon and a Maxillofacial surgeon. Objective: Facial deformities have profound impact on the social and psychological aspect of a person's life. Hence, management of facial wounds is very crucial. Most of the facial injuries are usually managed by emergency care physician and emergency surgeon. But certain wounds require specialised knowledge and care due to their complicated nature. The objective of this paper is to highlight those special types of wounds and the challenges they pose. It also aims to enumerate the best possible management according to each situation in a protocol-based manner, which will help in decision making by the attending emergency physician/surgeon. Methods: Facial lacerations were designated as "complicated" according to some pre-defined features and pre, intra and post operative data and photographs were collected by interviewing the concerned surgical team. The data were analysed and presented as different clinical scenarios. Results: The cases were broadly grouped under 6 scenarios according to the unique combination of difficulties faced and their specific management. The challenges faced were enumerated and the steps undertaken were also mentioned against them. Lastly, the scenarios were compared with available literature to find out the best possible management in each situation and to present them in a protocol-based manner. Conclusion: Protocol-based management of injuries to the different parts and specialised structures of the face is extremely helpful. Role of a specialised facial trauma team also should be emphasised in complicated facial injuries.

Cross Effects of Diets and Rearing Temperatures on Gastrointestinal Evacuation and Growth Performance in Adult Sabah Groupers (Epinephelus fuscoguttatus × E. lanceolatus).

This study explores the gastrointestinal evacuation time (GET) and gastrointestinal evacuation rate (GER) of the popular Sabah grouper (Epinephelus fuscoguttatus × E. lanceolatus) adults using two established methods (X-radiography and serial slaughter) and square root modeling using different temperatures: 28 °C, 30 °C, 32 °C, and 34 °C and different diets: pellet (ash: 11.4 ± 0.08; moisture: 29.0 ± 0.01; protein 37.5 ± 0.80; lipid 15.0 ± 0.13) and trash fish: Sardinella sp. (ash: 2.3 ± 0.15; moisture: 78.5 ± 0.33; protein 55.4 ± 0.62; lipid 7.3 ± 0.25) and the impact on growth indices. The results indicate that the GET shortened as temperature increased from 28 °C to 30 °C; however, it was prolonged when it surged to 32 °C and 34 °C. The groupers fed with trash fish at a temperature of 30 °C had the shortest GER (0.41 ± 0.10 g hr-1) whereas groupers fed with pellet at 34 °C had the longest GER (0.95 ± 0.02 g hr-1). Likewise, the highest SGR (16.25 ± 2.11% day-1) was observed at 30 °C for groupers fed with a trash fish diet. The condition (K) value was lowest at 34 °C for groupers fed with a pellet diet (1.01 ± 0.04) and highest at 30 °C for groupers fed with trash fish (1.45 ± 0.04). Our results suggest that temperature and diet influence growth indices and GE of adult Sabah groupers. Incorporation of this information will allow better management of this commercially important grouper species when reared in a controlled aquaculture environment.

The challenges and complications of re-implantation of the penis following amputation.

Amputation of the penis is a rare and devastating injury. The etiologies vary from accidental, self-inflicted to attacks due to sexual jealousy and revenge. In the present era of microvascular surgery, replantation is the standard care. However, replantation of the penis comes with its own set of difficulties and complications. Knowledge of the anatomy and prior knowledge of the possible complications makes the surgeon aware of the course of events after a replantation. It helps in devising strategies to overcome these challenges methodically. We present a case of penile replant with the complications that we encountered, and the measures are taken to counter them on our way to a successful outcome. Funding: No external funding.

Adamantinoma of tibia: excision and reconstruction with free vascularized fibula flap: a case report and review of literature.

Adamantinoma is a rare malignant tumour usually affecting the diaphysis of long bones. The tumour most commonly affects the tibia. Conventional management involves excision with a wide margin, reconstruction and sometimes amputation. Multiple options are available, but reconstruction depends upon the size of the bony defect and available resources. None has proved to be the favourable one. We have analysed the advantages and shortcomings of various methods used. In our case, a 33-year-old male patient presented with a large adamantinoma of the midtibial region of the left leg, which was managed with excision and reconstruction of long segment bony defect with free vascularized osteocutaneous fibula flap. There are osseointegration and hypertrophy of the vascularized bone with good functional gain in long term follow-up. Autologous bone reconstruction after adamantinoma excision with microvascular free fibula flap in large bone segment defects salvage the limb with satisfactory functional outcome.

Effectiveness of a microsurgery training program using a chicken wing model.

Microsurgical skills are essential for plastic surgeons in the modern times. Chicken wing model for microsurgery training offers an easy and cost-effective alternative to the traditional live rat model. A prospective study was conducted over a period of 6 months. Fifteen resident doctors in the department of plastic surgery were enrolled. Each of them underwent one session of microsurgery training on chicken wings (ulnar artery) every week for 15 weeks. The pre-training and post-training microvascular anastomosis were recorded and analyzed by two blinded investigators using a modification of the Structured Assessment of Microsurgery Skills (SAMS) tool. The pre- and post-training scores were compared. Twelve residents completed the requisite number of training sessions and were included in the final analysis. The mean diameter of the chicken wing ulnar artery was 1.04 mm (SD:0.11). All trainees demonstrated an improvement in the total scores. There was significant improvement in the mean scores (Pre-training: 33.46 vs. post-training: 41.42, p = 0.002). There was also a significant decrease in the total number of errors (Pre-training: 6.75 vs. post-training: 4.79, p = 0.012). However, there was no significant improvement in the average time taken to perform anastomosis (Pre-training: 58.03 mins vs. post-training: 52.51 mins, p = 0.182). We concluded that chicken wing is a useful training model for microsurgery. It helps in improving the overall microsurgical skill as well as reducing the average number of errors. This model is cost-effective, easily available, and easy to set-up. The wide assortment of vessels with varying diameters provides opportunities for training of microsurgeons of different skill levels.

Identification of Prognostic Factors in Spaghetti Wrist Injuries.

Background: Spaghetti wrist injuries involve a complete transection of three or more structures at the wrist level (including tendons, nerves, or arteries). Few studies on spaghetti wrist trauma have been reported in the literature, and most of them have focused on functional recovery rather than the prognostic factors which affect the outcome. We attempted to address some of the lacunae in current knowledge. Methods: Patients who were operated between January 2017 to January 2019 for spaghetti wrist injuries at a level 1 trauma center were included in the study. Several variables such as age, gender, smoking, education level, mechanism of injury, time gap between the injury to surgery, number of damaged structures and pattern of neurovascular structure were selected as potential prognostic factors to be included in the analysis. Motor recovery, sensory recovery & QuickDash score were used for the outcome assessment. A Multivariate analysis was done to identify the prognostic factor(s). Results: Thirty patients were included in the study. The mean age was 30.5 years (range: 7-57 years). Male population was predominantly affected (93.33%). The dominant limb was injured in 73.33%. The most common mechanism of injury was accidental glass cut (n = 19,63.33%), the most frequently affected structure was flexor digitorum superficialis of the middle finger (n = 23, 76.6%). Combined nerve injury was present in 23.33%. Intrinsic muscle recovery was affected significantly by presence of crush injury (e = 7.189, std error = 2.425, p = 0.003), education significantly affected power grip recovery (p < 0.0001), age was associated with pinch grip recovery (e = 0.083, std error = 0.039, p = 0.034). Conclusions: Increasing age, low education level, and presence of crush injury were identified as negative prognostic factors in the study. These findings may be used for counselling of patients affected by spaghetti wrist injuries.

Management of a Late Presentation of Bear Mauling with a Complex Maxillofacial Defect in a Tertiary Care Hospital - A Case Report.

Rationale: Bear mauling is the most common wild animal-inflicted injury in India. Ideally, these injuries should be managed early with fracture fixation, wound debridement, and appropriate coverage. Delay may lead to devascularization and a more severe deformity, which needs complex and multi-staged procedures for optimal outcome. Patient Concerns: Facial deformity in bear mauling is upsetting to the patient. Apart from facial aesthetics, the victim has difficulties in speech, eating, and respiration when the midface is involved. Diagnosis and Treatment: Patients require proper assessment of the soft tissue and bony defects by clinical assessment and imaging before planning any reconstruction. Outcome: The complex defect was managed in stages by both microsurgical and nonmicrosurgical methods including debridement, fracture fixation, local flaps, free flap, and prosthesis. Take-away Lessons: Systematic approach in categorizing each component of the problem, finding the best possible solution for each of them, and inter-departmental collaboration are important.

Thoracoumbilical Flap: Anatomy, Technique, and Clinical Applications in Upper Limb Reconstruction in the Era of Microvascular Surgery.

PURPOSE: Microvascular reconstruction is the standard of care for salvage of soft tissue defects in complex upper extremity due to their distinct advantages over the pedicled flaps. However, in the era of microsurgery, pedicled flaps have an acceptable significant role for reconstruction of complex soft tissue defects. The authors aim to demonstrate the versatility of pedicled thoracoumbilical flap (TUF) in selected clinical scenarios. PATIENTS AND METHODS: Retrospective analysis of patients who underwent TUF for upper limb posttraumatic reconstruction was performed between January 2016 and October 2017. The demographic details, etiology, wound parameters, clinical circumstances, and complications were recorded. RESULTS: Ten patients were included in the retrospective case series. Out of them, nine of the patients had critical issues, which justified a pedicled TUF over free flap. The critical issues were severe comorbid illnesses ( n = 3), the paucity of recipient vessels ( n = 1), salvage of hand replant and revascularization ( n = 2), circumferential degloving injury to the multiple fingers and palm ( n = 1), coverage for metacarpal hand ( n = 1), and extensive scarring at the surgical site ( n = 1). Mean age was 34.4 years (range: 11-70 years), six of them were males, and four were females. Two patients had infections resulting in wound gaping. One of the patients had flap tip necrosis. CONCLUSION: Pedicled flaps have a significant acceptable role in this era of microsurgery, and a pedicled TUF is a versatile option for coverage of complex soft tissue defects of the forearm, wrist, hand, and fingers. LEVEL OF EVIDENCE: This is a level IV, therapeutic, and retrospective study.

Detecting protein complexes in a PPI network: a gene ontology based multi-objective evolutionary approach.

Protein complexes play an important role in cellular mechanism. Identification of protein complexes in protein-protein interaction (PPI) networks is the first step in understanding the organization and dynamics of cell function. Several high-throughput experimental techniques produce a large amount of protein interactions, which can be used to predict protein complexes in a PPI network. We have developed an algorithm PROCOMOSS (Protein Complex Detection using Multi-objective Evolutionary Approach based on Semantic Similarity) for partitioning the whole PPI network into clusters, which serve as predicted protein complexes. We consider both graphical properties of a PPI network as well as biological properties based on GO semantic similarity measure as objective functions. Here three different semantic similarity measures are used for grouping functionally similar proteins in the same clusters. We have applied the PROCOMOSS algorithm on two different datasets of Saccharomyces cerevisiae to find and predict protein complexes. A real-life application of the PROCOMOSS is also shown here by applying it in the human PPI network consisting of differentially expressed genes affected by gastric cancer. Gene ontology and pathway based analyses are also performed to investigate the biological importance of the extracted gene modules.