Sathish Kumar Jayaraman

Severe burn injuries cause a hypermetabolic and hypercatabolic state, which increases the need for nutrients to support immunological response and wound healing.[1] The article introduces a simple, user-friendly digital application that applies the established Toronto formula to calculate the daily nutritional requirements of burn patients.[2] [3] All authors equally contributed to this article. The authors have conceived the idea and take full responsibility for the scientific content and relevance. Generative AI was used only to assist in the technical development of the application based on the authors' specifications. All outputs were reviewed and verified by the authors before including them. The authors take full responsibility for the outputs and results produced. Article published online: 12 August 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Private Limited A-13A, Graphix Tower 1, 6th floor, Sector 62, Noida 201309, Uttar Pradesh, India

Composite defects due to trauma present with compound comminuted fractures with soft tissue loss. Stabilization requires multiple Schanz pins across the fracture segments and flap cover for soft tissue reconstruction. These pins hinder flap inset and may require complex planning with multiple flaps. A simple approach is to impale the flaps over these pins to achieve flap inset without disturbing the skeletal fixation. This method of impaling was utilized for free as well as pedicled fasciocutaneous and muscle flaps. A stab incision is made and careful dissection is done to create a passage for the pins without injuring the vascularity of these flaps. In this manner multiple pins can be passed as needed. Flap inset is then completed. Slight modifications in threading the pins are required depending on whether a free or a pedicled flap is used. This study includes 16 flaps of which 15 were for lower limbs and 1 was for upper limb reconstruction. Pedicled flaps used were 13, the most common being inferiorly based fasciocutaneous flaps. Free flaps used were three, which included two muscle flaps and one fasciocutaneous flap. Two flaps were impaled in three places. All the flaps survived without any loss. Suture line dehiscence in four flaps was managed conservatively. Impaling the flaps on Schanz pins is a simple procedure to achieve soft tissue reconstruction in compound defects. Knowledge of the vascular anatomy and blood supply of the flaps is imperative in protecting the pedicle and maintaining the vascularity.

Dorsal toe skin defects present a significant challenge in reconstructive surgery. This report details the case of a 53-year-old male nonsmoker who presented with two nonhealing ulcers on the dorsum of his left great toe and second toe. The ulcers, which had developed spontaneously, persisted for 2 months despite conservative measures. The patient had a 10-year history of diabetes mellitus and was diagnosed with peripheral arterial disease (PAD), characterized by monophasic flow in the anterior tibial artery and triphasic flow in the posterior tibial artery. On examination, the ulcer on the dorsum of the great toe measured 3 cm × 2.5 cm and exposed the proximal phalanx bone. A second ulcer, measuring 2 cm × 1.5 cm, was located over the proximal interphalangeal joint of the second toe ([Fig. 1A]). The nature of the disease and available treatment options, including fillet flaps or toe amputation, were explained to the patient. However, he strongly desired to preserve his toes for as long as possible, leading us to explore alternative reconstructive strategies. Our vascular surgeons performed lower limb vessel angioplasty, successfully restoring triphasic flow in the anterior tibial artery, thereby improving perfusion to the affected toes. The ulcers were debrided until healthy bleeding was observed. To address the defect on the second toe, a cross-toe reverse dorsal adipofascial flap was harvested from the third toe. A glove tourniquet was applied to the base of the third toe. Dermal flaps were elevated from medial to lateral ([Fig. 1B]), and the adipofascial flap was elevated from lateral to medial, preserving the paratenon of the extensor digitorum tendon ([Figs. 1C] and [2]). The adipofascial flap was then sutured to the raw area on the second toe using 4–0 absorbable sutures, and a split-thickness skin graft was applied over it. The donor site on the third toe was closed with dermal flaps ([Fig. 3]). The ulcer on the dorsum of the great toe was covered using a transposition flap from the medial side. The donor site was closed with a split-thickness skin graft ([Fig. 1D, E]). The cross-toe adipofascial flap between the third and second toes was divided 2 weeks later. At follow-up, both the great toe and the second toe wounds demonstrated successful healing ([Fig. 1F]). The management of PAD through angioplasty was critical in restoring adequate blood flow, which facilitated wound healing.[1] The dorsal and plantar metatarsal arteries primarily supply the toes, and the adipofascial flap technique preserved these vital vascular supplies. Various reconstructive options for dorsal toe defects have been described, including local homo-digital flaps, homo-digital reverse-flow island flaps, and lateral toe pulp flaps.[2] [3] [4] While the cross-toe adipofascial flap is rarely reported in the literature, the cross-finger adipofascial flap is well documented and effective for dorsal finger defects involving exposed tendons or bones.[5] Although the outcome in this case was satisfactory, toe flaps should be used cautiously in patients with PAD due to the potential risks of compromised perfusion. Article published online: 07 January 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

In the evolving landscape of health care, patient education has become a cornerstone of effective treatment and recovery. With the government's focus on Digital India, electronic handouts are increasingly important. This article examines the use of electronic patient handouts versus traditional printed materials, highlighting the role of quick response (QR) codes in enhancing access to health information. Article published online: 03 September 2024 © 2024. Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Indocyanine green (ICG) is a fluorescent dye commonly used in lymphovenous bypass (LVB) surgery to identify lymphatic vessels. ICG binds to proteins in lymphatic fluid and makes them visible under near-infrared light. During the surgery, a specialized near-infrared camera, built into a modern microscope, is used to visualize the lymphatic vessels that have taken up the ICG dye.[1] Additionally, ICG can be used after the surgery to assess the patency of the newly created lymphovenous connections. Our department has a Zeiss microscope (S 8) for microvascular anastomosis, lacking the capability for ICG filter integration. To circumvent the problem, we used a laparoscope camera with a built-in ICG filter (Stryker Advanced Imaging Modality Camera 1588) for our LVB procedure. A 34-year-old female had developed lymphedema in her right upper limb after undergoing treatment for breast cancer, which was managed by compression dressing during the coronavirus disease period. Despite this, the patient's swelling continued to gradually increase, prompting her to undergo a LVB procedure almost a year after the mastectomy. This procedure was the first of its kind to be performed at our hospital. However, the old Zeiss microscope used for microsurgery did not have a fluorescence imaging option available. To overcome this limitation, we attempted to use a laparoscopic camera with an ICG filter, which is typically used to visualize the bile duct.[2] The camera was adjusted for white balance and then switched to ICG filter mode. The camera is typically positioned above the surgical site and is connected to a display screen that allows the surgeon to see the images in real-time ([Fig. 1]). ICG injected into the subcutaneous tissues of the distal forearm ([Fig. 2]), which is absorbed by the lymphatic, results in green fluorescence on the monitor ([Fig. 3]). The lymphatic channels were easily visualized during the procedure and LVB was successfully completed using the old Zeiss microscope.[3] The laparoscopic camera equipped with an ICG filter serves as a valuable tool for LVB in settings lacking access to a contemporary and costly microscope. Article published online: 30 January 2024 © 2024. Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Background Choosing the components of free flap (fasciocutaneous or muscle) is one of the crucial but controversial decisions in heel reconstruction. This meta-analysis aims to provide an up-to-date comparison of fasciocutaneous flaps (FCFs) and muscle flaps (MFs) for heel reconstruction and to ascertain if one flap has an advantage over the other. Methods Following the Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed identifying studies on heel reconstruction with FCF and MF. Primary outcomes were survival, time of ambulation, sensation, ulceration, gait, need for specialized footwear, revision procedures, and shear. Meta-analyses and Trial Sequential Analysis (TSA) were performed to estimate the pooled risk ratios (RRs) and standardized mean difference (SMD) with fixed effects and random effects models, respectively. Results Of 757 publications identified, 20 were reviewed including 255 patients with 263 free flaps. The meta-analysis showed no statistically significant difference between MF and FCF in terms of survival (RR, 1; 95% confidence interval [CI], 0.83, 1.21), gait abnormality (RR, 0.55; 95% CI, 0.19, 1.59), ulcerations (RR, 0.65; 95% CI, 0.27, 1.54), footwear modification (RR, 0.52; 95% CI, 0.26, 1.09), and revision procedures (RR, 1.67; 95% CI, 0.84, 3.32). FCF had superior perception of deep pressure (RR, 1.99; 95% CI, 1.32, 3.00), light touch, and pain (RR, 5.17; 95% CI, 2.02, 13.22) compared with MF. Time to full weight-bearing (SMD, –3.03; 95% CI, –4.25, –1.80) was longer for MF compared with FCF. TSA showed inconclusive results for comparison of the survival of flaps, gait assessment, and rates of ulceration. Conclusion Patients reconstructed with FCF had superior sensory recovery and early weight bearing on their reconstructed heels, hence faster return to daily activities compared with MFs. In terms of other outcomes such as footwear modification and revision procedure, both flaps had no statistically significant difference. The results were inconclusive regarding the survival of flaps, gait assessment, and rates of ulceration. Future studies are required to investigate the role of shear on the stability of the reconstructed heels.