Bibhuti Bhusan Nayak

Muscle conserving free gracilis transfer (mini-gracilis free flap)

Gracilis is a commonly used muscle for free tissue transfer. It is also split into two based on its pedicles and used as two units. Use of distal part as a free flap in isolation has never been described in literature. We describe a technique of harvesting a small unit of gracilis based on its minor pedicle and maintaining the continuity and conserving the major bulk of muscle. Thus, the function of the muscle is preserved and the same is also available for transfer on its major pedicle later, if required.

Considerations for double-hand replantation in a resource-constrained healthcare facility.

Bilateral-hand amputation is extremely rare and double-hand replantation is even rarer. Only one case of successful double replantation at arm level has been reported from India. We present a case of double-hand replantation at proximal palmar level in a young adult executed in a small nursing home. The patient presented 5 h after injury with limbs preserved well in ice. There were difficulties in executing such an unusual case in a small nursing home set-up. The patient is performing his activities of daily living and basic functions independently. We share our experience of this double-hand replantation with special emphasis on problems encountered.

Cutaneous tuberculosis, tuberculosis verrucosa cutis

Cutaneous tuberculosis because of its variability in presentation, wider differential diagnosis, and difficulty in obtaining microbiological confirmation continues to be the most challenging to diagnose for dermatologists in developing countries. Despite the evolution of sophisticated techniques such as polymerase chain reaction (PCR) and enzyme-linked-immunosorbent serologic assay (ELISA), the sensitivity of new methods are not better than the isolation of Mycobacterium tuberculosum in culture. Even in the 21 st century, we rely on methods as old as the intradermal reaction purified protein derivative standard test and therapeutic trials, as diagnostic tools. We describe a case which has been diagnosed and treated as eczema by renowned physicians for 2 years. Incisional biopsy showed the presence of well-defined granulomas and ZN staining of the biopsy specimen showed the presence of acid fast bacilli; a trial of ATT (antitubercular therapy) for 6 months lead to permanent cure of the lesion.

Single stage reconstructions in head and neck surgery using deltopectoral and pectoralis major myocutaneous flaps

Even though free tissue transfers are a routine in many centres, pedicle flaps still have a huge roll to play in our country. There are many centres in the country where pedicle flaps are in use because of logistic problems. Deltopectoral and pectoralis muscle flaps are usually preferred for composite cheek defects. When both these flaps are used in combination it is a two-staged procedure. We describe a single-stage procedure to reconstruct a composite cheek defect with pectoralis major myocutaneous flap for lining and single-stage deltopectoral flap for cover. In the available literature search, single-stage DP and PMMC have not been described for management of composite cheek defect.

Partial duplication of lower lip and hemimandible A rare case.

Duplication of mandible and lower lip is a very rare congenital entity. We report an extremely uncommon case of Congenital Duplication of Lower lip and Mandible in a 3 year old girl, who was treated surgically in a single stage for correction of both lip and mandible. This was a commissure preserving single staged procedure. The Surgical procedure, the problems related to this anomaly and the embryology are discussed.

Reverse vastus lateralis musculocutaneous flap for Marjolin's ulcer over the knee joint

Marjolins ulcer is a rare and often aggressive cutaneous malignancy that arises in previously traumatized or chronically inflamed skin, particularly after burns. Treatment modalities of Marjolins ulcers include wide local excision, block dissection of the regional nodes, amputation in advanced lesions of limbs, radiotherapy, and chemotherapy. Wide local excision, together with skin grafting, is usually considered appropriate in the treatment of Marjolins ulcers. For lesions that are located at critical places skin grafting cannot be done because either the excised bed will not take the graft or skin grafting can be done but due to the unstable nature is often avoided preferring a flap cover. Defects over the knee is challenging especially when the defect is quiet large and the surrounding skin is scarred and unhealthy. In such situations neither any local fasciocutaneous flap nor muscle flap is possible, the only option left are in the form of free tissue transfer. But if this type of situation can be managed by transferring tissue from the upper part of the thigh in the form of pedicled flap then other complex reconstructions can be avoided. We describe a case of a 45-year-old male with Marjolins ulcer over the post burn scar of right knee for 5 years duration with no regional or distant metastasis managed with wide local excision and cover with reverse vastus lateralis musculocutaneous flap. The post op outcome is uneventful with better patient satisfaction.

Pedicled latissimus dorsi flap for arm defects: A report of twenty-three cases

Background: The latissimusdorsi muscle or myocutaneous flap is one of the most reliable and versatile flaps used in reconstructive surgery. It is known for its use in chest wall and post mastectomy reconstruction and has also been used effectively for coverage of large soft tissue defects in the head and neck and upper limb either as a pedicled flap or as a free flap. It has been described for reconstruction of hand and foot defects as microvascular flap and functional reconstruction of elbow in brachial plexus injuries. Aim: Evaluate its role in reconstruction of arm defects. Patient and Methods: Twenty three cases of pedicled Latissimus dorsi flaps for arm defects are enrolled into the study. The cause of the defect, the site and size of the defect, associated injuries and timing of flap cover are also noted. Observaion and Result: Out of 23 cases majority of defects are from trauma (19 cases) and rest from neoplastic resection (4 cases) all belonging to the age group of 15-45 years with defect size ranging from 10 × 15 cm 2 to 15 × 25 cm 2 . The average duration of follow up was 6 months to 1 year. All the flaps survived without partial loss. Six patients developed seroma at flap donor site which settled with multiple aspirations. Two patient developed hyper trophy at the borders at the donor site scar. Three patients had stretching of the scar. There were no other donor site complications at the flap or skin graft sites. All patients have cosmetically satisfactory result. Conclusion: Pedicled Latissimus dorsi muscle and musculocutaneous flap with a split thickness skin graft is the primary choice for reconstruction of large complex arm defects.

Reconstruction of high voltage electric burn wound with exposed shoulder joint by thoracoacromial artery perforator propeller flap.

We describe the reconstruction of high voltage electric burn injury with exposed shoulder joint by thoracoacromial artery perforator propeller flap based on the delto-pectoral perforators of thoracoacromial artery. The successful use of this propeller flap to cover the exposed shoulder joint in a case with limited local flap options demonstrates its use as an alternative technique.

Primary intra osseous venous malformation of nasal bone: A rare case report

Primary intra osseous venous malformation with involvement of nasal bone is a rare phenomenon. Nasal bone intraosseous venous malformation on a back ground of port wine stain of face has not been reported in the available literature. We report the very rare case of intraosseous venous malformation of left nasal bone developing on a background of port wine stain of face, its diagnosis, pathology, management and review of literature.

Rare case of nasolacrimal duct opening into face

Congenital anomaly of nasolacrimal duct is mostly obstructive in nature or is seen in oblique facial clefts. Nasolacrimal duct drain into the inferior meatus in the nose in a normally developed face. We report a rare case of aberrant opening of distal end of nasolacrimal duct into the external skin lateral to the ala of nose in an adult patient. The only case reported so far was in an infant. The patient is a 22 year young male presenting with an opening lateral to the left ala of nose with recurrent discharge and conjunctivitis of left eye. The embryology is also discussed.