V. Bhattacharya

Lingual Mucosal Graft Urethroplasty for Anterior Urethral Strictures

OBJECTIVE To evaluate the effectiveness of a lingual mucosal graft (LMG) urethroplasty for anterior urethral strictures and the donor site complications. METHODS A total of 30 patients underwent urethroplasty for anterior urethral strictures using dorsal on-lay of a LMG from March 2006 to December 2006. Most patients had balanitis xerotica obliterans as the etiology. The mean stricture length was 10.2 cm (range 3.7-16.5). Postoperatively, all patients underwent pericatheter urethrography at 3 weeks, followed by retrograde urethrography with micturating cystourethrography, and uroflowmetry at 3 and 6 months. Repeat uroflowmetry was done as, and when, required. RESULTS The mean period of follow-up was 9 months (range 4-12). The overall success rate was 83.3%. The mean peak flow rate increased postoperatively from 4.36 mL/s to 35.5 mL/s at 3 months and 25.06 mL/s at 6 months of follow-up. One patient developed repeat stricture at the anastomotic site, and 4 patients developed recurrent meatal stenosis. CONCLUSIONS The results of LMG urethroplasty were comparable to that of buccal mucosal graft urethroplasty. LMG is easy to harvest. Most importantly, the donor site complications were minimal without any functional or esthetic deficiency.

Detail microscopic analysis of deep fascia of lower limb and its surgical implication.

Background: The knowledge regarding the structural details of deep fascia remains inadequate. It was described to be relatively avascular having predominantly protective function. Anatomical and surgical studies revealed that it had associated vascular arcade and hence incorporated it to ascertain additional vascularity to the flaps. However, not much importance has been directed towards the detailed study of the various constituents of deep fascia in order to explain its physiological and clinical implications. Therefore, this study was undertaken to unveil these details. Materials and Methods: Fifty fresh specimens of human deep fascia overlying the gastrocnemius muscle were analyzed regarding the (i) vasculature, (ii) matrix, and (iii) other structural elements. The deep fascia was procured in three forms; (a) both the layers, (b) superficial layer, and (c) deep layer. Detail study was conducted by light, confocal, and electron microscopy. Results: Under light microscopy, blood vessels including capillaries were seen associated with both the layers. Perforators traversing the intra-fascial plane could be visualized. Confocal microscope optical sections showed well-organized bright fluorescent collagen fibers and nuclei of various cells. Electron microscopic evaluation revealed many interesting constituents which are relatively unknown to the anatomist and clinicians. There were arterioles, capillaries, venules, lymphatics, nerves, mast cells, and myofibroblasts apart from collagen and elastic fibers. Conclusion: The detail structural analysis of deep fascia provided the clue to its rich vascularity and other structural constituents. They all contribute to enhance the vascularity and maintenance of the physiological functions of fasciocutaneous, adipofascial, and fascial flaps, frequently used for reconstructions. Thus, incorporation of deep fascia in the flaps during reconstruction is highly beneficial for ensuring optimal vascularity.

Cleft palate associated with hamartomatous bifid tongue. Report of two cases

Congenital tumours of the tongue may have a detrimental effect on the simultaneously developing adjacent structures. Palate formation may be affected as it develops in the same period of organogenesis as the tongue. We present two such rare cases of cleft palate with tumour of the dorsal tongue as the probable causative factor. To analyse such an entity, it is necessary to understand the embryogenesis of the palate and tongue. The management and possible elucidation of the occurrence with respect to the developmental phases of tongue and palate are detailed in brief.

Distal perforator based cross leg flaps for leg and foot defects

The cross leg fasciocutaneous flaps are less frequently indicated for distal leg and foot defects due to the availability of other alternative options. However they still remain one of the more realistic options for the surgeon in situations like unsuccessful attempt of free flaps, non-availability of ipsilateral proximal calf tissue, damaged distal perforators following trauma, burns, radiation etc., and inadequate reach beyond mid sole. In the present article we share our experience emphasizing the significance and use, with redefined indications and surgical technique of cross leg retrograde fasciocutaneous flaps for various distal leg and foot defects. We are of the opinion that these flaps are still useful as they continue to prove to be the flap of choice in demanding situations.

CT angiographic evaluation of perforators in the lower limb and their reconstructive implication

Background: The perforator flaps evolved on the knowledge of the vascular tree from the main vascular trunk up to the subdermal plexus. Therefore, we thought that its necessary to map the whole vascular arcade by CT angiography. The aim of this study is to evaluate the perforators and the whole vascular tree of the lower limb by peripheral CT angiography with 3D reconstruction and intraoperative evaluation. This study helps in designing flaps of different constituents based on the selected perforators. Materials and Methods: Twenty patients having lower limb defects were selected. CT angiography was done using a non-ionic iodinated contrast media injected through the antecubital vein. The lower limbs were imaged using volume rendering CT scan machine. Three dimensional reconstructions were made. The whole arterial tree, along with the perforators, were mapped. Findings of the audio-Doppler were correlated with the CT angiographic observations. Further these evaluations were confirmed by intraoperative findings. Results: The three dimensional CT angiographic reconstruction with bone and soft tissue provided advanced knowledge of this vascular network. It delineated the main vessel, the perforators, their caliber, distance from fixed bony landmarks and course up to the subdermal plexus. These findings were confirmed during dissection of the proposed flap. The perforators were mainly musculocutaneous in the proximal leg and septocutaneous distally. Conclusions: The vascular details visualized by this technique made advancement over the existing methods namely color Doppler, audio Doppler, two dimensional angiography etc. It improved the understanding of perforator flaps and their successful clinical application.

V-Y gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: a simple solution.

BACKGROUND Compound defects of the Achilles region pose a reconstructive challenge. Poor vascularity of the Achilles region predisposes to complications. Repair of the tendon with simultaneous soft-tissue cover gives the patient the best chance to recover. MATERIALS AND METHODS Gastrocnemius musculotendinous V-Y slide for Achilles tendon defect with non-axial turnover fascial flaps based on the proximal end of the defect with a split-skin graft on the fascial flap was used in two patients. The vascular bases of such flaps and the technical details has been discussed. RESULTS The functional and aesthetic results were highly satisfactory with minimal donor-site morbidity. The flap was thin enough to fit the contour of the Achilles region. The fascial flap with skin graft was durable and withstood footwear well. The flap also allowed tendon gliding beneath it, with near-complete movements at the ankle joint. CONCLUSION Large flaps can sufficiently be raised with a wide base to cover small- to medium-sized defects. It is a good, rapid and cost-effective solution for a difficult clinical problem.

GLI3 mutations in syndromic and non-syndromic polydactyly in two Indian families.

The GLI3 protein is a zinc finger transcription factor, expressed early in development. The GLI3 gene exhibits allelic heterogeneity as mutations in this gene are associated with several developmental syndromic and non‐syndromic polydactyly. The present study reports two cases: first, a familial case of Greig Cephalopolysyndactyly Syndrome (GCPS); the second is a sporadic case with both postaxial polydactyly (PAP) type A and B. Resequencing of GLI3 gene reveals a previously reported nonsense truncation mutation g.42007251G > A (p.R792X; rs121917714) in the GCPS family and a novel single nucleotide insertion g.42004239_42004240insA (p.E1478X) in the sporadic case of postaxial polydactyly (PAP). Both nonsense truncation mutations; p.R792X (GCPS) and p.E1478X (PAP) introduce a premature stop codon leading to loss of C‐terminal domains.

Repair of burns of the scrotum using a gracilis myocutaneous flap

An unusual case of isolated burns of the scrotum reconstructed by a unilateral gracilis myocutaneous flap is reported because of its clinical rarity.

Electrophysiological and histological changes in extrinsic muscles proximal to post burn contractures of hand

Burn scar hand contractures of variable degree are frequently encountered. Although the forearm is apparently spared, it was clinically observed that there was disuse atrophy in the unburnt extrinsic forearm muscles. Usually the clinicians do not give much importance to this fact. The girth at the midforearm was significantly reduced as compared to normal side. The flexion of the hand joints are governed by two components (a) intrinsic and (b) extrinsic muscles. The intrinsic muscles are directly involved in the contracted tissue. Therefore it was thought essential to evaluate the extrinsic group of muscles for their contribution in the final functional recovery following corrective surgery. Thirty patients having unilateral post thermal burn contracture sparing forearm were studied. A detailed clinical evaluation was made including grade of contracture and reduction in the forearm girth. The forearm unburnt muscles were evaluated by preoperative electrophysiological studies. Intraoperative biopsies were taken from these muscles for histopathological examination. On histopathological examination, there were significant abnormal changes in the form of muscle fiber atrophy, fibrolipomatous tissue replacement of atrophic muscle fibers and sarcolemmal changes. These changes were directly proportional to the severity of contractures. The electrophysiological studies showed proportionate changes in the form of reduction in amplitude, duration and interference. This study suggests that if these changes are mild and in reversible stage, they will favourably affect the functional recovery following surgery. However if these changes are of severe grade and irreversible, in spite of adequate surgery, splinting and physiotherapy, the functional recovery may not be complete.

A novel GLI3c.750delC truncation mutation in a multiplex Greig cephalopolysyndactyly syndrome family with an unusual phenotypic combination in a patient

Greig cephalopolysyndactyly (GCPS) syndrome is an autosomal dominant disorder with high penetrance in majority of cases, characterized by a triad of polysyndactyly, macrocephaly and hypertelorism. GCPS is known to be caused by mutations in the transcription factor GLI3 gene (7p13) which results in functional haploinsufficiency of this gene. The present study reports a large multiplex family having 12 members affected with GCPS in 3 generations and several unaffected members showing autosomal dominant pattern of inheritance with complete penetrance. Interestingly an affected member of the family had unusual features including thumb which is although biphalangeal (confirmed with X-ray) but morphologically looks like finger and a unilateral tiny bony outgrown (externally indistinguishable) on the distal phalanx of the first toe of the left foot. This member also presented with mild ichthyosis. Although it is also possible that one or more of these features are coincidentally present in this member and might not be part of GCPS. Resequencing of the GLI3 gene detected a novel frame-shift mutation c.750delC in heterozygous state transmitting in the family and co-segregating with the disorder suggesting it to be the causal for the GCPS phenotype in the family. In silico analysis suggests that this mutation creates a truncated GLI3 protein resulting in its haploinsufficiency leading to GCPS syndrome. Furthermore, genotype-phenotype correlation is supported by the mutation as it lies in the amino terminal domain of the protein.