Donor Finger Morbidity in Cross-Finger Flap: A Systematic Review and Meta-Analysis

Background The morbidity of donor finger in a cross-finger flap has not received as much importance as the outcomes of the flap itself. The sensory, functional, and aesthetic morbidity of donor fingers, reported by various authors, are often contradictory to each other. In this study, objective parameters for the sensory recovery, stiffness, cold intolerance, cosmetic outcome, and other complications in the donor fingers, reported in the previous studies, are systematically evaluated.

Methods This systematic review is reported using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol and was registered with the International prospective register of systematic reviews (PROSPERO registration no. CRD42020213721). Literature search was done using “cross-finger,” “heterodigital,” “donor finger,” and “transdigital” words. Data regarding demography, patients' number and age, follow-up duration and outcomes of donor finger, including 2-point discrimination, range of motion (ROM), cold intolerance, questionnaires, etc. were extracted from included studies. Meta-analysis was performed using MetaXL and risk of bias was evaluated using Cochrane risk of bias tool.

Results Out of the total 16 included studies, 279 patients were objectively evaluated for donor finger morbidity. Middle finger was most frequently used as donor. Static two-point discrimination seemed to be impaired in donor finger in comparison to contralateral finger. Meta-analysis of ROM suggested that statistically there is no significant difference in ROM of interphalangeal joints in donor and control fingers (pooled weighted mean difference: −12.10; 95% confidence interval: −28.59, 4.39; I2 = 81%, n = 6 studies). One-third of donor fingers had cold intolerance.

Conclusion There is no significant effect on ROM of donor finger. However, the impairment that seems to be in sensory recovery and aesthetic outcomes needs to be further evaluated objectively.

Effectiveness of Nasolabial Flap Versus Paramedian Forehead Flap for Nasal Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Different studies performed on nasal subunit reconstruction by either the nasolabial flap or the paramedian forehead flap have reported contradictory outcomes and complications, claiming one flap or the other as superior. This inconsistency has led to a gap in existing literature regarding the preferable flap for nasal reconstruction. Our aim was to statistically evaluate and compare these two flaps for nasal reconstruction, in terms of subunit preference, complications, and outcomes, using data from previous studies.

METHODS

This systematic review is reported using PRISMA protocol and was registered with the International prospective register of systematic reviews. The literature search was done using "paramedian forehead flap", "nasolabial flap", "melolabial flap", "nasal reconstruction". Data regarding demography of study and population, subunit reconstructed, complications, and aesthetic outcomes were extracted. Meta-analysis was performed using MetaXL and summary of findings using GRADEpro GDT.

RESULTS

Thirty-eight studies were included, and data from 2036 followed-up patients were extracted for the review. Meta-analysis was done on data from nine studies. Difference in alar reconstruction by forehead versus nasolabial flap is statistically significant [pooled odds ratio (OR) 0.3; 95% CI 0.01, 0.92; p = 0.72; I² = 0%, n = 6 studies], while for dorsum and columella reconstruction the difference is not statistically significant. Risk of alar notching is marginally more in forehead flap, however difference in incidence of partial/complete flap necrosis, alar notching and hematoma/bleeding among the flaps is not statistically significant.

CONCLUSION

Alar reconstruction is preferred by nasolabial flap. Complications are similar in both groups. Comparison of aesthetic outcome needs further exploration.

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 .

Difference between Capillary Blood Glucose of Free Flap and the Patient: A Novel Objective Marker of Free Flap Vascular Compromise during Postoperative Monitoring

Background Defining cut-off values of flap glucose levels in diagnosing free flap vascular compromise, without taking patients' glucose levels into account, does not hold good in all circumstances, especially in cases of high fluctuations in patients' capillary blood glucose and in diabetic patients. The aim of our study was to establish the role of capillary blood glucose measurements of the flap in relation to patients' fingertip, as an objective tool for postoperative free flap monitoring.

Methods A total of 76 free flaps underwent postoperative monitoring with reference test (clinical parameters) and simultaneously with our index test (difference between capillary blood glucose of free flap and the patient), in non-diabetic and diabetic patients. Patients' demography and flap characteristics were also recorded. An ROC curve was plotted to determine diagnostic accuracy and cut-offs of the index test in diagnosing free flap vascular compromise.

Results Our Index test has a cut-off value of 24.5 mg/dL with 68.75% sensitivity and 93% specificity, with an accuracy of 91.54%.

Conclusion The difference between capillary blood glucose of free flap and the patient is simple, feasible, and inexpensive, and can be done by any health care professional and does not require any specialized facilities or training. It has an excellent diagnostic accuracy to detect impending free flap vascular compromise, especially in non-diabetics. Although in diabetics, this test becomes less accurate. Being an observer-independent objective test, the difference in capillary blood glucose of patient and flap measurement can be used as a highly reliable tool for postoperative free flap monitoring.

A Systematic Review of the Sensory Outcomes of a Standard Cross-Finger Flap Reconstruction for Fingertip Defects

Background: The standard (dorsal) cross-finger flap (CFF) is one of the common flaps used for fingertip reconstruction. There is little consensus regarding the sensory outcomes associated with this flap. In this systematic review, we evaluated objective sensory outcome parameters of patients who underwent CFF reconstruction. Methods: This systematic review is reported using the PRISMA protocol and was registered with the International Prospective Register of Systematic Reviews. Literature search was done using the terms 'cross-finger flap', 'heterodigital', 'finger-tip' and 'transdigital'. Data regarding the number of patients, follow-up duration and sensory outcomes, including 2-point discrimination (2-PD) were extracted from included studies. The analysis was performed using Microsoft Excel with MetaXL add-in software. Certainty assessment and summary of findings table was created using GRADEpro GDT. Results: This review includes 14 studies with 301 patients. We found a statistically significant difference in static 2-PD of recipient and control fingers (pooled weighted mean difference [WMD]: 1.66; 95%CI: 0.03, 3.29; p = 0.00; I²=92%, n = 7 studies). Conclusions: Dorsal CFF reconstruction for fingertip defect does not provide adequate sensory recovery. Level of Evidence: Level III (Therapeutic).

Expanded Paramedian Forehead Flap for Nasal Reconstruction Following Congenital Nevus Excision

In this report, we discuss the excision of a large congenital nevus covering the nose and face and the reconstruction of the defect using an expanded forehead flap, in a 24-year-old man. We observed that after incorporating specific modifications including tissue expansion, thinning of the distal part of the flap, and placing the pedicle over the cutaneous branch of the supratrochlear artery, we were able to provide excellent aesthetic results using this time-tested paramedian forehead flap for nasal reconstruction. After we inset the flap, there was negligible donor site morbidity during a 33-month follow-up period.

Creating a Microdissection Cautery Tip Using Disposable Needle

The use of electrocautery is universal in modern day surgery. Through decades electrocautery has reformed from larger electrodes to smaller ones. The latest modification is the micro-dissection cautery with a fine electrode tip. We have modified the electrocautery tip to replicate the usage of micro dissection-cautery using readily available, low cost disposable needle. The idea is to replicate the benefits of micro-dissection needle with a low cost construct which can be learned easily, used widely to provide optimum surgical results to the wider sections of the society. A video demonstration for creation of the micro-dissection cautery construct is also demonstrated.

Two-staged reverse sural flap: a versatile flap with consistent results in the soft tissue reconstruction of distal leg and heel defects-an institutional experience

BACKGROUND

Reverse sural flap (RSF) is commonly used for soft tissue reconstruction of distal leg and heel defects. The classic method of flap transfer is the single-staged cutaneous islanded reverse sural flap (SS-RSF). This method is associated with variable flap complications notably the venous congestion. The other form of flap transfer is the two-stage reverse sural flap (TS-RSF), in which the pedicle of the flap is exteriorized in the first stage. Flap division and re-inset are done in the second stage. The aim of this paper is to review the flap outcomes and complications among the SS-RSF and TS-RSF reconstruction of soft tissue defects in the distal leg and heel.

METHODS

This is a retrospective chart review of RSF being operated in a tertiary care hospital. The duration of study was 1.5 years. Twelve RSFs (6 SS-RSF, 6 TS-RSF) were done for soft tissue defects in the distal leg and heel. Wounds of various etiologies (traumatic, chronic, non-healing ulcers) were reviewed. Trauma was the most common etiology with 8 out of 12 (66.7%) patients. Large wounds, donor site damage and patients with peripheral vascular disease were excluded from the study.

RESULTS

Five out of six (83.3%) of TS-RSF healed uneventfully. However, 3 out of 6 (50%) of SS-RSF had partial flap necrosis. All complicated flaps healed well subsequently. No donor site complication was found in any of our patients.

CONCLUSION

Pedicle exteriorization in TS-RSF eliminates the element of venous congestion and eventually flaps necrosis. Less technical expertise and minimal morbidity are additional advantages of TS-RSF.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

'Hand inside glove': Useful method of burn dressing in children

The use of sterile surgical gloves in wound dressing is not new. It has been used previously in dressing of fresh wounds and in adjunct to the negative pressure wound management. Herein we describe an interesting case of burn wound dressing of hand in a child. Low cost, easy availability, better patient compliance and lesser chances of wound infection are special attributes of glove dressing.

Dhoti cancer revisited

Dhoti is traditional Indian dresses worn by males in the Indian subcontinent to cover the lower parts of the body. The term Dhoti cancer was first used by Khanolkar and Suryabhai in 1945. It is a type of waistline SCC reported in Indian males wearing dhoti. Only a handful of cases are reported in English literature. This case is remarkable due to its rare site of presentation, simultaneous presence of carcinoma and suspicious acanthosis on both side of waist in the same patient. Any hypo pigmented patch and acanthosis on the waist area in a dhoti clad man should be viewed with suspicion and continuous surveillance is needed thereof.

Access to the Skull Base - Maxillary Swing Procedure - Long Term Analysis

Background:

Skull base is difficult to approach surgically due to its complex anatomy. A number of procedures that is endoscopic, microscopic, and open approaches have been used. The maxillary swing approach provides a wide exposure to the surgeon for better oncological clearance.

Patients and Methods:

A total of 62 patients with varied etiologies involving the skull base region were operated with maxillary swing procedure over a period of 15 years from 2001 to 2016 in plastic surgery department at a single institution.

Results:

There was no recurrence in the follow-up period. One patient had palatal fistula and one patient had mild nasal mucosal atrophy. None of the patients had malocclusion in the postoperative period. The minimum follow-up period was 24 months.

Conclusion:

Maxillary swing procedure provides excellent exposure to skull base, and most of the tumors involving this region can be effectively excised with minimal morbidity to the patient.

A Comparative Study of Histopathology of Astrocytomas with Intraoperative Cytology with Special Reference to MIB-1 Labelling Index

BACKGROUND

Although radiological imaging and surgical techniques have substantially improved, assessment of prognosis by grading astrocytoma has been challenging task for pathologists. We have tried to assess these tumours intraoperatively for rapid diagnosis. Also MIB-1Labelling index (MIB-1 LI) was done to study their proliferative activity.

AIMS

To compare and grade squash smear technique with histopathology to study its utility in diagnosis of astrocytomas. Further, to study correlation of various grades with their MIB-1 labelling index.

SETTING AND DESIGNS

This study was carried out in the Department of Pathology, SMS Medical College, Jaipur over a period of one year.

MATERIALS AND METHODS

Forty five cases of radiologically suspected astrocytomas were submitted for intraoperative cytology and later for histopathology. Two techniques were compared for ability to diagnose as well as grade the tumour. Also, MIB-1 LI were performed in biopsy tissue. Histopathological and immunological grades were compared.

RESULTS

Out of 45 cases 44(97.7%) correctly diagnosed by squash smear technique. Further significant differences seen in values of MIB-1 LI of high-grade and low-grade astrocytomas. A progressive increase in the MIB-1 LI was observed with increasing grades. In grade I astrocytoma MIB-1 LI was <0.05%. In grade II astrocytoma it varied from 0.8-2.6% except in one case where it was 3.2% who presented with a recurrent mass. In grade III, MIB-1 LI was 3.5% to 7.5%. In grade IV was 10-20%.

CONCLUSION

Intraoperative cytology is fairly accurate and useful in intraoperative consultation. Also, MIB-1 LI can be a useful adjunct for grading particularly in small biopsies.