Angioleiomyoma is an uncommon benign vascular smooth muscle tumor, representing <1% of soft-tissue neoplasms in the upper extremity. Its rarity, variable symptoms, and nonspecific imaging features frequently lead to misdiagnosis, with lesions mimicking ganglion cysts, giant cell tumor of tendon sheath, schwannoma, leiomyosarcoma, or glomus tumor. Multidisciplinary radiology review plays a key role in evaluating such indeterminate hand masses. A 57-year-old male presented with a gradually enlarging, painless palmar swelling. Magnetic Resonance Imaging revealed a well-defined, heterogeneously T2-hyperintense subcutaneous lesion with intramuscular extension, tendon encasement, and involvement of the radial digital nerve—features that generated a broad differential at the institutional radiology conference. Surgical exploration showed an encapsulated tumor encasing several digital nerve fibers, which were repaired following en bloc excision. Histopathology demonstrated smooth muscle bundles around thick-walled vessels with myxoid change but no atypia. The presence of myxoid stroma and neurovascular encasement raised concern for neurogenic and other spindle-cell lesions, necessitating targeted immunohistochemistry (IHC). Smooth muscle actin and Desmin positivity with S-100 and Pan-TRK negativity confirmed angioleiomyoma. This case illustrates the diagnostic complexity of palmar angioleiomyoma, driven by clinical ambiguity, nondiagnostic imaging, myxoid stromal change, and unusual neurovascular involvement. Accurate diagnosis requires thoughtful integration of clinical, radiologic, intraoperative, and histopathologic findings. Focused IHC is essential to differentiate angioleiomyoma from its mimics and to guide appropriate management.
Background Accurate angle construction is fundamental to successful Z-plasty. Conventional tools such as protractors are often impractical in operative settings due to sterility issues, difficulty on curved surfaces, and workflow disruption. We developed a simple ruler-based technique using multiplication factors (0.25X, 0.5X, 0.7X, 0.9X, 1.0X) to construct standard angles without specialized instruments. Objective The aim of the study is to validate a simplified ruler-guided multiplication-factor technique for constructing Z-plasty angles without angle-measuring instruments and to assess its accuracy, reliability, and clinical feasibility. Materials and Methods This prospective two-phase observational study included (Phase 1: 50 tracings per angle) derivation and reproducibility testing of multiplication factors for standard Z-plasty angles by five surgeons and (Phase 2) clinical validation in 32 consecutive patients undergoing Z-plasty. Ruler-guided designs were compared with sterile protractor measurements. Primary outcomes were agreement assessed by intraclass correlation coefficient (ICC) and Bland-Altman analysis. Secondary outcomes included plotting time, surgeon-reported usability, and early postoperative complications. Results Multiplication factors demonstrated high reproducibility (SD <= 0.03) with minimal interobserver variability. Clinical validation showed excellent agreement between ruler-guided and protractor-based measurements (ICC 0.94; 95% CI 0.90-0.97). Bland-Altman analysis demonstrated a mean bias of 0.8 degrees with limits of agreement from -3.1 degrees to +4.7 degrees. Plotting time was significantly shorter using the ruler-guided technique (22 +/- 6 second vs. 65 +/- 12 second p <0.001). Surgeon usability scores were high (mean 9.1/10). No complications attributable to planning error were observed. Conclusion The simpler ruler-guided multiplication-factor technique provides clinically equivalent angular accuracy to protractor-based design while offering superior speed, ease of use, and applicability on curved surfaces. Its simplicity and universal availability make it a practical alternative for routine Z-plasty planning, particularly in high-volume and resource-limited settings.
Reconstruction of axillary defects after oncologic resection is particularly challenging in patients with prior axillary dissection and radiation, as traditional thoracodorsal-based flaps may be unreliable. We present a case of a 59-year-old woman with recurrent left axillary invasive ductal carcinoma, 18 years after lumpectomy, axillary dissection, chemotherapy, and radiation. En bloc resection involving the pectoralis minor and serratus anterior created a 6 × 5 × 2 cm defect with exposed rib. A lateral intercostal artery perforator (LICAP) flap was used for reconstruction, based on a dominant perforator at the sixth intercostal space identified by Doppler and confirmed intraoperatively with indocyanine green angiography. The flap was de-epithelialized, tunneled to the axilla, and the donor site closed primarily. The patient achieved complete healing without necrosis or contracture and maintained full shoulder mobility after adjuvant chemoradiation. The LICAP flap offers a safe, reliable option for axillary reconstruction in previously treated fields.
Post-surgical pyoderma gangrenosum (PPG) is an underdiagnosed variant of a neutrophilic dermatosis that mimics postoperative wound infections, delaying correct diagnosis and treatment. This case series presents 10 female patients who developed PPG following elective aesthetic breast and abdominal surgeries. The average onset of symptoms was 11.4 days postoperatively, with painful ulcerated lesions localized to surgical wounds, often misinterpreted as infection. Diagnosis was primarily clinical and confirmed histologically in 50% of cases. Systemic corticosteroids were the cornerstone of therapy, combined with immunosuppressants in 80% of cases. Hyperbaric oxygen therapy was used in six patients, with excellent clinical response. The average time to clinical resolution was 5.7 months, with no recurrence. Despite successful management, all patients developed unaesthetic scarring. This series reinforces the importance of early suspicion of PPG in atypical postoperative wound evolution and highlights the role of multidisciplinary treatment combining immunosuppression and adjuvant wound care modalities.
The peer-review system, the backbone of research quality control, is showing signs of serious strains. Finding qualified and willing reviewers is getting difficult, and reviewers either don't even acknowledge the receipt of the review invitation or reject it outright, if it is even marginally outside their comfort zone. Editors are overburdened with a high volume of submissions. This requires efficient triage and a keen understanding of diverse scientific fields. The peer-review process is getting increasingly difficult, particularly if the editor wishes to get timely assessments from busy domain experts. Then again, ethical considerations are also vital, particularly around bias and misconduct, and this too demands rigorous scrutiny. The emergence of artificial intelligence in research has added a whole new dimension, as it poses both opportunities and complications. While there should be no issue if artificial intelligence is being used to improve the language of text, any further assistance demands clear guidelines to maintain the value of human authorship and reviewership. Clearly, the time has come to incentivize the reviewers, and journals have to think of ways of doing so without encountering conflict of interest.
Congenital or acquired anomalies of the penis can lead to significant physical and psychological problems in a patient. Goals of urethral reconstruction is to create a functional meatus with a patent tube for micturition and ejaculation. In a patient with penoscrotal hypospadias we reconstructed 13 cm length of the urethra using a two-stage procedure. In the first stage, we prefabricated a flap using the hairless groin skin with the descending branch of the lateral circumflex femoral artery. In the second stage, the flap was transposed and tubed to create the neourethra. Long segment urethral reconstruction using prefabricated hairless groin skin flap based on the descending branch of lateral circumflex femoral artery is a new technique of near-total urethral reconstruction to the best of our knowledge and can be used to treat difficult cases of urethral reconstruction for varied indications, giving us a simple and innovative technique in reconstructive armamentarium.
Background Electrical burn injuries represent a severe subset of burn trauma, often complicated by deep tissue necrosis, systemic effects, and limb loss. In India, rapid industrialization, poor infrastructure safety, and limited public awareness contribute to a disproportionately high burden. Although limb amputation has been linked to voltage intensity, burn mechanism, and delayed presentation, prospective data remain scarce. This study aimed to analyze the clinical patterns and determinants of limb loss in electrical burn patients and to identify independent predictors of adverse outcomes. Materials and Methods This was a prospective observational study conducted over 24 months (May 2023-April 2025) at a tertiary burn center in Western India, enrolling 110 consecutive patients with electrical burns. Data on demographics, injury characteristics (voltage, burn type, total body surface area [TBSA], cause), clinical course, and outcomes (limb salvage, amputation, mortality) were systematically collected. Statistical analysis employed chi-square tests, t -tests, and binary logistic regression to identify independent predictors of amputation and mortality. This study enrolled 110 patients based on feasibility and patient flow during the study period. No formal prior sample size calculation was performed, which may limit the statistical power of some analyses and is acknowledged as a study limitation. Results Electrical burns accounted for 7.3% of all burn admissions, with a mean age of 27.6 +/- 13.7 years and male predominance (85.5%, p < 0.0001). Seasonal clustering was observed during the monsoon months (48.6%, p < 0.01), with young adults aged 21 to 40 years most affected. High-voltage injuries comprised 67.3% of cases and were significantly associated with amputation (39.2% versus 8.3% in low-voltage, OR 5.2, 95% CI: 2.8-9.6, p < 0.001). Contact burns predominated (50%), followed by flash (26%) and mixed types (24%). Occupational exposures accounted for 44% of cases and formed the dominant pathway to amputation, while agricultural exposures showed the highest amputation rate (53.8%). Overall mortality was 12.7%, confined to high-voltage injuries (18.7% versus 0% in low-voltage, p < 0.01), with TBSA (58 +/- 17%) and ICU admissions (71%) strongly associated with fatality. Post-mortem findings revealed lung congestion (71%), renal hemorrhage (57%), and sepsis (36%) as leading causes of death. Discussion Limb loss and mortality in electrical burns were governed not by TBSA alone, but by voltage strength, mechanism of burn, and occupational/environmental risk context. The predominance of high-voltage occupational contact injuries underscores infrastructural and workplace vulnerabilities, while agricultural exposures emerged as particularly hazardous. Conclusion This study highlights that electrical burn outcomes in India are largely preventable yet remain devastating, with high-voltage occupational contact injuries most strongly linked to limb loss and mortality. Preventive strategies focusing on workplace safety, infrastructural improvements, and seasonal awareness campaigns are essential to reduce the burden.
Over the past five decades, plastic surgery has transformed from a niche specialty into a widely accepted, technology-driven field. In the 1980s, the profession was defined by its emphasis on craftsmanship and authority, with a clear divide between the "respected realm" of reconstructive surgery and the "often-stigmatized" world of cosmetic procedures. The 1990s introduced minimally invasive techniques such as Botox and lasers, fostering a more collaborative surgeon-patient relationship. The 2000s saw the rise of digital imaging and the internet, empowering patients and shifting decision-making dynamics. In the 2010s, the integration of prevention, wellness, and mental health became central to practice. By the 2020s, advancements like bioprinting and AI-enabled personalized treatments emerged, raising new ethical considerations. Today, plastic surgery is democratized and mainstream, combining surgical expertise, regenerative medicine, and psychological support. Surgeons now serve as partners in patients' identity journeys, balancing empowerment with ethical responsibility.
Background Congenital upper limb anomalies (CULA) are common, but the actual magnitude of the problem within the community remains undetermined due to a lack of a registry system. Our study aimed to determine the epidemiology of CULA, its syndromic associations with other systems, to identify and categorize upper limb anomalies according to the International Federation of Societies for Surgery of the Hand (IFSSH) classification, to study the inheritance pattern of the disease, and to investigate the association of risk factors during the antenatal period. Materials and Methods This ambispective study was conducted at a tertiary care center from January 2022 to July 2024. Exclusion criteria included stillbirths, vascular malformations, congenital peripheral nerve disorders, and birth brachial plexus injuries. Comprehensive demographics, antenatal, perinatal, and postnatal histories, as well as family pedigrees, were documented. Each CULA case was classified according to the IFSSH guidelines, and statistical analysis was performed using Stata 18.0. Results There were 148 cases, with 5 dropouts, with a mean age of presentation being approximately 7 years, with approximately 58% males and approximately 42% females. The ratio of bilateral:right:left was 3.8:1.7:1. The most common non-hand involvement was in the foot, with the ratio of bilateral:right:left being 13.4:4.5:1. The mean birth weight was 2.75 kg, and the mothers' mean age at the time of birth was 26 years. There were three cases born to a consanguineously married couple, and four cases were detected on ultrasonography, with no significant correlation. There was positive familial correlation in IFSSH II, III, and VI categories, with p-values of 0.037, 0.001, and 0.026, respectively. The most common occurrence was seen in the IFSSH II category (98 cases) and the least in the IFSSH VI category (7 cases). Conclusion A substantial gap exists in the literature regarding the epidemiology and registry systems for CULA, rendering the full extent of the issue within communities ambiguous. However, IFSSH II is the most common anomaly with a varying pattern. Positive family history is commonly observed in IFSSH II, III, and VI groups, and syndromic associations are more prevalent in groups I and VII.
Introduction:Chronic facial paralysis severely compromises facial symmetry and function. The free gracilis muscle flap has become the gold standard for dynamic facial reanimation. This study aims to evaluate the functional and aesthetic outcomes of gracilis free muscle flap procedures performed at the Facial Paralysis Clinic of Hospital General "Dr. Manuel Gea González," using the Terzis Functional Grading System and the eFACE (Electronic Facial Paralysis Assessment) digital assessment tool. Materials and Methods:A retrospective, cross-sectional, and analytical study was conducted on 52 patients who underwent free gracilis muscle flap surgery for facial reanimation between 2018 and 2023. Inclusion criteria were chronic facial paralysis and complete pre- and postoperative assessments using the Terzis grading system. In unilateral cases, the eFACE scale was also used. Functional and aesthetic outcomes were analyzed using paired Student's t -tests. Results:Of the 52 procedures, 62% involved unilateral paralysis. The most common etiology was classic Moebius syndrome (35%). Significant functional improvement was observed on the Terzis scale, with mean scores increasing from 1.1 to 3.1 postoperatively ( p < 0.01). In unilateral cases, the eFACE scale demonstrated significant improvements in static symmetry, dynamic movement, midface/smile, and lower face/neck domains. No significant changes were observed in synkinesis or periocular function. Postoperatively, 52% of patients achieved good outcomes (group IV), and 86% of procedures were free of complications. Conclusion:The free gracilis muscle flap significantly improves facial function and aesthetic in patients with chronic facial paralysis. These findings validate its effectiveness and highlight the value of objective assessment tools for outcome measurement and future research.
Background Upper limb tissue defects may result from trauma, infection, burns, or tumor resection. Small superficial defects are amenable to skin grafting, whereas larger full-thickness defects with a wide zone of injury require coverage with pedicled or free flaps. The goal of reconstruction in upper limb defects is not only to achieve coverage but also to restore motor and sensory function as well as aesthetics. Materials and Methods In this randomized study, patients who underwent resurfacing of upper limb defects between July 2022 and June 2024 were divided into two groups: distant pedicled flap (Group 1) and free flap (Group 2). Aesthetic, sensory, and functional assessment were performed at 3 and 6 months postoperatively, and statistical significance was analyzed between the two groups. Results A total of 40 patients were enrolled, with 22 patients in the pedicled flap group and 18 in the free flap group. Aesthetic analysis using the Likert scale showed better results in the free flap group. Both subjective and objective functional assessment showed better results in the free flap group at 3 months, with comparable results in both groups at 6 months. Sensory assessment showed similar results in both groups. Conclusion With free tissue transfer, better overall outcomes were observed, including improved aesthetic appearance, earlier functional recovery, earlier return to work and daily activities, and better quality of life. In the presence of a dedicated microsurgical team, better reconstructive goals can be accomplished in upper limb reconstruction.
Background Venous leg ulcers (VLU) are a significant global health challenge, predominantly resulting from chronic venous insufficiency, requiring effective treatment to enhance healing and quality of life. This study aimed to evaluate the efficacy of hyperbaric oxygen therapy (HBOT) in conjunction with four-layer compression bandage (4LCB) therapy in VLU management. Materials and Methods A randomized controlled trial was conducted at a tertiary care center in northern India and included 70 patients aged >15 years with chronic venous ulcers. Patients were randomized into two groups: Group A (n = 35) received 4LCB therapy with adjunct HBOT, and Group B (n = 35) received 4LCB therapy alone. Both groups received standard medical therapy, and follow-up assessments were conducted at 2, 4, 6, and 8 weeks. The primary outcomes were reduction in ulcer size and healing time, while secondary outcomes included quality of life assessed using the EQ-5D-5L and Charing Cross questionnaires. Results Group A showed a significantly greater reduction in ulcer size compared with Group B (p = 0.006). Quality-of-life scores improved significantly in both groups, with Group A demonstrating better Charing Cross scores (p = 0.033). A moderate positive correlation was found between healing time and pre-therapy ulcer size in both groups. Conclusion VLU affects patients' lives due to pain, difficulty with locomotion, exudate, odor, and repeated hospital visits. It has been proven that multilayered compression bandages, achieving 20 to 30 mm Hg of pressure, effectively reduce venous hypertension, and lead to effective ulcer healing. HBOT has also been shown to be beneficial for VLU in retrospective single-arm studies. This randomized control trial exhibits significant ulcer size reduction and improvement in quality of life in both arms. However, the addition of HBOT to standard 4LCB therapy significantly reduces the mean post-therapy ulcer size and improves post-therapy quality of life in patients with VLU compared with 4LCB therapy alone. There is scope of further studies on the effects of various HBOT regimens on ulcer healing and the use of HBOT in combination with venous surgeries.
Aims This study investigates the protective role of subcutaneous fat in preventing pressure sores, integrating ultrasound and finite element analysis (FEA) to understand the biomechanical mechanisms. It aims to explore the correlation between subcutaneous fat thickness and pressure sore risk as indicated by Braden scale scores. Materials and Methods A total of 100 bedridden patients from the Spine Ward and Pulmonary Medicine intensive care unit were enrolled. Subcutaneous fat thickness in the sacral region was measured using ultrasound, and Braden scale scores were recorded. FEA was used to simulate stress and strain distributions in the muscle and fat layers for varying fat thickness. Statistical analysis was performed using analysis of variance, post hoc Tukey test, and Pearson's chi-square test to correlate fat thickness with mechanical parameters. Results The results demonstrated a significant negative correlation between subcutaneous fat thickness and pressure sore risk. Patients with lower Braden scale scores (higher risk) had thinner subcutaneous fat. FEA models showed that increased fat thickness reduced maximum total deformation, equivalent stress, and shear stress in muscle and bone tissues. Conclusion Subcutaneous fat plays a crucial protective role in preventing pressure sores by reducing mechanical strain on tissues. This study highlights the potential for using subcutaneous fat thickness measurements as a predictive tool for pressure sore risk and suggests the exploration of fat grafting as a preventive strategy.
Bone shortening is performed during replantation of major crush avulsion amputations. It ensures fixation of healthy bone ends, helps avoid vein, nerve grafts, and additional soft tissue procedures, thereby reducing ischemia time. When amputations occur near joints, bone shortening may lead to joint loss. A 12-month-old infant suffered amputation just proximal to the articular surface of the humerus. The humerus fragment was small for any stable fixation and any shortening of the proximal segment would offer a vastly different cross section for rigid fixation. To preserve elbow joint, a 3 cm of humerus segment was osteotomized from the proximal segment. The resected bone segment was fixed as a free bone graft to the humeral distal articular surface with Kirschner wires. A 3-cm further shortening was done in the proximal segment and fixed to the distal side. The free bone segment survived as graft with bone union at both sides with joint preservation.
