Reverse Peroneal Artery Flap for Large Heel and Sole Defects: A Reliable Coverage.

BACKGROUND: Large soft tissue defects of ankle and foot always have been challenging to reconstruct. Reverse sural flaps, free flaps have been used for this problem with variable success. Reverse peroneal artery flap is an option to use with reliability without microvascular repair. Connections of peroneal artery around talus and ankle joint are deep and reliable with anterior tibial and posterior tibial artery. Arterial inflow and venous drainage improved with including short saphenous vein and reverse sural artery in the flap. METHODS: Ten patients with large defects around heel underwent reconstruction with (RPAF) reverse peroneal artery flap (pedicled) over a period of 2 years. Final inset given after 18-21 days of primary surgery. The mean age of these patients was 45 years. RESULTS: Of the 10 flaps, all showed complete survival without even marginal necrosis. Two patients had minor donor site problems that settled with conservative management. CONCLUSION: RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel and sole. Large defects can be reconstructed without microvascular surgery and without compromising major vessel of foot region. If some experience with perforator flaps and free fibula is there then RPAF is easy to execute with reliability.

What is safe limit of the perforator flap in lower extremity reconstruction? Do we have answers yet?

We make an attempt to define the safe extent of local perforator flap for lower limb reconstruction by comparing it with the limb length of the patient. The maximum flap length from the perforator was compared to the limb length in 35 patients using EPI info 6.04 D software. On comparison of flaps that were less than one-third of limb length to those which were more than one-third of limb length, the statistical values were significant. The odds ratio calculated was 6, which means that there is a six times more chance that a local perforator flap will necrose if it is more than one-third of the limb length as compared to a flap which is less than one-third of the limb length.

Free tissue transfer for trophic ulcer complicating leprosy.

Plantar ulceration is the commonest disability in leprosy and occurs in about 10 to 20% of leprosy patients. Various loco-regional flaps have been described for reconstruction of trophic ulcers; however, very large defects are not amenable to local flaps and free flaps form one of the important treatment options. We present a case of a post Hansen's trophic ulcer over the forefoot managed using a radial artery forearm free flap. Debridement of the osteomyelitic bone, removal of the bony prominences, coverage by a well-vascularised tissue, end-to-side arterial anastomosis, use of anterior tibial as the recipient vessel and good postoperative compliance in foot care on the part of the patient gave us good results.

Project Muskan: Social responsibility of the plastic surgeon.

Although exact statistics are not available, Indian plastic surgeons see around 7,00,000-8,00,000 burn admissions annually with around 10,00,000 cleft patients yet to be operated. In spite of this voluminous load, India does not have national health programs for the various deformities Indian plastic surgeons typically treat. As Plastic Surgeons, it is our social responsibility to treat these patients and bring 'muskan' (smile in Hindi) back into their lives. Project Muskan was initiated as an innovative model for targeting these patients and is probably one of its kind in the field of plastic surgery in our country. It is unique because it is a perfect collaboration of government institutions, a Non Government Organization (NGO), and cooperative sectors providing free health care at the doorstep. Identification of the patients was done with the help of the extensive milk dairy network in the state of Gujarat. Provision of transport and other facilities was done by the NGOs and quality health care provision was taken care of by the government hospital. Project Muskan started from a single village but now covers around 3000 villages and tribal areas of Gujarat. It is a system that can be easily reproducible in all hospitals and has reestablished the faith of the common man in government institutes.

Maxillonasal dysplasia (Binder's syndrome) and its treatment with costal cartilage graft: A follow-up study.

Maxillonasal dysplasia or Binder's syndrome is an uncommon congenital condition characterized by a retruded mid-face with an extremely flat nose. We report here six patients with maxillonasal dysplasia whose noses were corrected with onlay costal cartilage grafts using a combined oral vestibular and external rhinoplasty approach for nasal dorsal augmentation, columellar lengthening, and premaxillary augmentation. The cartilage graft was dipped in a solution of 100 ml 0.9% NaCl and one vial (80mg) gentamicin for 30 min to prevent warping. L struts made for nasal augmentation, columellar lengthening, and premaxillary augmentation were fixed to one another by slots made in the graft. This technique has been used in children, adults, and for secondary cases with promising results. All patients were of class I dental occlusion. The nasal and premaxillary augmentation which was monitored by serial photography was found to be stable over a follow-up period of three years.

Complete cleft of the upper limb: A very rare anomaly.

BACKGROUND: We describe here a very rare congenital deformity that involves the splitting of the right upper limb with the superior limb articulating with the shoulder joint, and the inferior limb laterally attached to the chest wall. MATERIAL AND METHODS: The child with this rare split limb was treated by transferring the inferior limb on an islanded pedicle to the superior one while creating the hand. RESULTS: A unified limb was reconstructed while creating the hand without any compromise on the existing function and vascularity. The patient is on regular follow-up and further staged procedures have been planned to provide a better functional and aesthetic limb. CONCLUSION: The congenital deformity described here has not been mentioned in world literature so far and its embryological basis is a matter of discussion. Opinions regarding further management of this anomaly are invited from experts in the field.

Microneurovascular reimplantation in a case of total penile amputation.

Amputation of the penis is a rare condition reported from various parts of the world as isolated cases or small series of patients; the common aetiology is self-mutilating sharp amputation or an avulsion or crush injury in an industrial accident. A complete reconstruction of all penile structures should be attempted in one stage which provides the best chance for full rehabilitation of the patient. We report here a single case of total amputation of the penis, which was successfully reattached by using a microsurgical technique. After surgery, near-normal appearance and function including a good urine flow and absence of urethral stricture, capabilities of erection and near normal sensitivity were observed.