Well, I know that people are joining the webinar now. We're going to give it about 30 seconds before we formally start. As you join, you'll have the ability to ask questions through the chat function. So just be aware of that. We won't be able to hear you directly, and we'll try our best to answer these questions. So I'm going to go ahead and begin the webinar. I wanted to introduce by saying this is the inaugural webinar between the ASPS and the Association of Plastic Surgeons of India. It's been a venture, Dr. Sabapati, who's my co-chair between the understanding between ASPS and APSI. We've been working for several years to see this realization, and this is really the first year we've been able to do it. We're so proud and so proud of the various participants who are on the webinar, who'll be speaking to three of the great surgeons of India who are leaders and contributors to clinical medicine. I just wanted to underscore the longstanding relationship that the ASPS and PSF have had with the leaders of plastic surgery in India. This was APSICON, the APSI meeting in Lucknow in 2018, and you can see of the five people standing there who are the leaders of that meeting from Lucknow, all five had been international scholars with the Plastic Surgery Foundation, and four of them actually spent time with me, which is how I've gotten to have such a close relationship with all of the great leaders of plastic surgery in India, and it's such a proud moment to see all of them coming together and being able to present this global webinar. But the history of plastic surgery in India, as you all know, goes well beyond APSI. It goes to the origins of our specialty with Sushruta, and he was really the key innovator in plastic surgery throughout, and India is so proud of his legacy, and this is when Dr. Iyer was the chair in 2017, then in 2018 in Lucknow, how proud they are of that heritage, and now we're so proud to be part of that heritage in joining with APSI and the ASPS. I'm going to turn it over to Dr. Sabapathy at this point to complete the webinar. Well, welcome all of you. It's a proud moment for the members of the Association of Plastic Surgeons of India, and I do this on behalf of President and President-elect who are also in the panel. As Dr. Ghazain said, it has been a long dream which has come true, and we have in this webinar three outstanding surgeons of India present on their work, and each of them will be speaking for about 15 minutes on their chosen topic in which they have had a large volume of experience, and I'm sure it will be very interesting. Just to make things easy, we thought we'll go through all the presentations one by one, and at the end of it, we'll take your questions. We welcome you to put your questions, the audience to put the questions in the chat feature, and then surely we will take it on at the end of it. So without taking much of time, I would like to introduce our first speaker, Professor Rakesh Karsanchi. He is the current president of the Association of Plastic Surgeons of India, and with me who is moderating the session is Ravi Mahajan, who is going to be the incoming president of the Association of Plastic Surgeons of India, and we have a past president in Subramania here and an upcoming senior surgeon, Dr. Rajan Naiti. Dr. Rakesh, in addition to being the president of the Association of Plastic Surgeons of India, is the chairman of a very busy hospital in New Delhi called the Medanta Medical City Hospital, and he will be speaking to us on CAD CAM in complex craniofacial reconstruction. Over to you, Rakesh. Rakesh sir, please unmute yourself. Sir, in the left. Okay. Okay. Okay. Got it. Can you hear me now? Yes. Yes. Yeah. Okay. I just give me a moment. I'm just getting my first slide in. On the screen. We had in a moment. Thank you, Raja, for the nice introduction. And now that we are in the COVID era and this everything is becoming digital. So I thought that it would be apt that we start this presentation using computer aided design and manufacture in complex craniofacial reconstruction. As you all are aware that majority of oral cancer, mandibular and maxillary reconstructions are more and more being done by using CAD CAM technology. However, in this presentation, I am not going to be talking about oral cancer. This Dr. Subramanian Iyer will cover later. So I'm going to talk about where are the what are the other areas in craniofacial region where we have been using this technology. So virtual surgical planning alone or with models, guides or patient specific implants are the areas where we have used them. Virtual surgical planning is the first part that we started initially when we were doing it. And that is basically to use the 3D reconstruction and models for just for planning surgery. Now here is a patient with mandibular prognathism and maxillary retrusion. And here what we use was a 3D cephalometry instead of using a two dimensional regular cephalogram, we used a 3D cephalometry. And what we were able to conclude from that was that we would need six millimeter of maxillary advancement, six millimeter of mandibular setback, and also a three millimeter genioplasty. Having done that, this is I'm not going into any more detail. So this just was used for planning. I'll show you the pre and post of this patient. And what you see here is occlusion after the surgery. And if you see that our plan was bilateral BSSO with maxillary advancement and a genioplasty. And you see this plan reproduced with the fixation that we were able to reproduce it quite well and get a good result. Going further, this is a patient who presented to us with facial asymmetry. We were wondering whether this was hemifacial microsomia. There was a little chin deviation towards the left. And when we did an animation with a sliding genioplasty, we could see that this is what, you know, we could foresee the result that we could obtain by just a sliding genioplasty. Although initially we were thinking we might need some fat injection on the face as well. So this is pre and post-op and just with a simple operation planned with the help of CAD CAM, CAD rather computer aided design that we were able to get this result. And another patient with bilateral TM joint enkelosis and micrognathia. Basically, we did the planning using again 3D reconstruction. We knew that on the right side, we will need less distraction as compared to the left side. And after we had done the distraction, we realized we were still a little bit behind. And then again, an advancement genioplasty was required. And this was of 6 mm genioplasty, which was going to be done. So this is the patient during distraction. And this is the patient after. What you see here is this is pre-op and this is post-distraction, but before genioplasty and this is after genioplasty. And the same patient in the same three views at different times. The second part in this is we use models with virtual surgical planning. And this is our next part. This is a patient with an orbital fracture on the left side. And this is how we planned this operation. The patient's virtual 3D model was made and then it was bisected and two equal halves were made. And the right normal side was mirrored onto the left side. And it was then gave us what the model of left side was going to be on which the plate was adapted. And this adapted plate, after the exposure, we didn't have to do any plate adaptation. This was put in place. And this is the result that we got after this sort of surgery. We could probably do it without computer modeling as well, but I think it made the surgery easier. And also the plate adaptation, once you do it on an orbit, which is outside, is done in two dimensions. It's not just that we have to get a concavity in the posterior area. We also have to get a convexity. And we have to make sure that the medial part of the defect is covered completely. This patient had a right coronal synostosis. And basically we printed a model of the skull. And then it was easy to plan and also practice the actual surgery we were going to do. And also how much advancement was required. We could calculate that our original requirement seemed to be 1.5 centimeter, but 5 millimeter of overcorrection was done. And this is the intraoperative bend you and the frontal craniotomy, barrel staving enclosure. And this is the result after six months after the surgery. So this, again, the major advantage here was that it was easier for us and the planning was done very well on the model. And it was more easily executed. And then we move on to the next step after we gain more experience as to by printing guides for different kinds of surgeries. Again, another patient with coronal synostosis on the left side. And this is the 3D picture of the skull. And what we did here was we not just planned the osteotomy, but we were also able to print the guides for osteotomy. So this is the model that we will fit on the skull once the exposure was done. And this is the upper cut of the osteotomy. And that is the lower cut, which will go over the supraorbital region. And this is the printed skull. And this shows how we were going to make the cuts. So again, without going into details of surgery, this is a child pre-op. You can see the deformity looking at the eyebrow and the eye. Also the deformity in the posterior parietal region got corrected on its own. We didn't have to do anything to that. This patient had a right temporal fibrous dysplasia. And this is the CT scan with 3D reconstruction. And what we did here was we planned the surgery. Again, virtual planning was done. And a cutting guide was printed. This was 3D printed. And this was again practiced on the skull model first. Then it was used intraoperatively. What you see here is the guide is in place. And then it's stabilized with some screws as there is place for them. And having done that, we will then just take an oscillating saw or whatever saw you are comfortable with and just shave this thing off and finally remove the guide and just burr out the edges. Again, makes it a little simpler to do the surgery as we have followed the plan that we have already made and used the cutting guide. So this is the patient pre- and post-op. Again, the same patient. Another patient with fibrous dysplasia. And what you see here is that he's got involvement of the zygoma, maxilla, superior orbital rim. So this is a rather complicated process. And we made prepared cutting guides, sequential cutting guides. First cut will remove this part of the zygomatic bone. And having done that, the second guide will remove the part which is lower down, part of the maxilla. And the third guide was going to cut out the superior orbital rim. And these are the guides on models. Again, intraoperative showing guides. And this is pre- and post-op after surgery. Again, I think the surgery was made very simple by using this method. And we've also used planning of surgery in fractures by doing a virtual reduction here. The virtual reduction is in progress. The mandible is reduced. The maxilla is reduced. The occlusion is obtained. And then we plan a wafer, which occlusion wafer, that is going to be used. And then we remove everything else. And we just print the wafer. And this is the wafer that we use to get proper occlusion and reduction during surgery, just to make matters simple. And at the end of surgery, we remove the wafer. Going further, another patient with blast injury. He's had a free fibula reconstruction earlier. But you can see the fibula was inadequate. There is a collapse of the chin area. And we did, again, what we do here is to first do virtual surgery, remove and get the mandible into occlusion. And then we prepare a model of the, you know, which is going to be made from fibula. And that precise model is replicated in reconstruction, again, using CAD-CAMP. And you see that even the inferior margin of mandible is completely made. This is pre-op and this is post-op, again, pre- and post-op. The last part that I'm going to touch upon is patient-specific implants that we have used with virtual surgical planning. This is a grown-up adult patient with right coronal synostosis. And the after effects of that is the depression in this area. And then what we see in other views is that you see this is basically a cosmetic problem. And you see the, appreciate the depression more here. So the method here is to, again, bisect what we call rapid prototyping. You take the left side, which is normal, then reverse it and put it, place it over the right abnormal side. And by subtraction, we know that this is the implant that we are going to need. And when this implant is going to be manufactured in the OT by using a mold, that is going to be, again, made from the, by computer planning and then 3D printed. And this is a short video where we'll show you how the, this implant is prepared intraoperatively. So this is a bicaronal incision. And in the region of where we're going to place the implant, it's going to be subperiosteal dissection. And the area of implant placement is exposed. And polymethyl methacrylate is used, it's mixed up, it's put in the mold. And then once we've done that there, the mold is complete. And once the PMMA sets, we just open up the mold. We have to line it with some neosporin ointment so that it doesn't stick. And there you are. The implant comes out, made right on the table. And just that the edges have to be fashioned, checked on a skull model, printed skull model. Now it is placed on the patient and just fixed with a few screws. And you see, this is pre and post, again, pre and post, pre and post. And again, this is where you appreciate the best. Going further, I think malgenated fractures of the left of the zygomatic or maxillary complex are very difficult to treat. And you see here is a patient who had facial fractures, but this fracture reduction was not proper. And what there is no, it's very difficult to refracture and bring them into proper reduction. So we plan an implant. This implant will be made in two portions and same technologies, the technique is used to make the implant. And here you see pre and post with the kind of correction that we were able to achieve with the implant introduced through a bicoronal incision. And this is actually from the post-op CT. You can see the implant here exactly as we had planned. Another patient with a mandibular deviation with micrognathia and also chin deviation. We need to plan an asymmetric implant here. You see the implant is bigger on the left side. And here it is intraoperatively. And what you see here is pre and post-op again, pre and post-op. Another patient, right zygomatic or maxillary complex fracture, malgenated. You see the frontal area is also involved, and this is totally in shambles. Left side is normal. Again, by same rapid prototyping technique, we prepared this implant. And we've also planned the mesh for the orbital floats support, the frontal bone implant, the zygomatic implant, and then the mesh in place here. And this is pre and post, pre and post. And this is the CT reconstruction post-operatively. You see this big implant, frontal bone, zygomatic bone, and maxillary bone. And this is a patient actually before she had the accident. This is when she came to us, and this is what she is now. Another patient with the malgenated maxillary fracture with loss of bone here. You see there is a palatal fistula, and he has malocclusion. So what we plan here is a leafort 1 osteotomy to get it into occlusion, which will be different segments and a fibula for reconstruction of the bone and for the bone gap, and also planned dental implants for this patient. So this is pre and post again. Again, you see that the fistula is closed, and also we have got good occlusion. This is probably my last patient that I will be showing. And this was a real challenge. He came to us. He had a fibromyxoma of the left zygomatic maxillary complex. And this is the CT of the patient you see here. Although it's a benign tumor, it can be locally aggressive. And the bones were like already, you know, expanded to the limit. And you see this is an actual animation of the 3D reconstruction. You see the kind of the extent of tumor. So when we planned the surgery, we do this planning along with our head and neck surgeon, and this is the excision that was going to be done. And having excised that, what would we do for this reconstruction of this defect was something of a challenge. So we used both microsurgical and CAD CAM techniques to reconstruct this. We used a free fibula for the upper jaw, and we used implants, manufactured implants for the zygoma, maxilla, and floor of orbit and the lateral wall and all the other extensions of these bones. And this is the segment that was removed as planned. So the fibula was planned with a segment for the palatal closure and a segment for the nasal closure and muscle to fill up the cavity and the pedicle to go to the superficial temporal vessels. And these are the implants in two parts, which will reconstruct the rest of his bony loss. And these are intraoperative pictures. And you see here, this is pre and post. Again, pre and post and pre and post. And the original computer planning was here, and that is the post-op CT. And he has since has had dental implants placed also to complete the reconstruction. So we have, since this part of this work is in press, in publication in Journal of Career Facial Surgery, at that time we had 32 implants in 25 patients, and we had one patient where there was implant exposure, and we lost this implant. This was because of a poor choice. I think this patient had previous radiotherapy, and that's not the method that we should have used. Looking at the literature, there is, you know, the PMMA implants, infection rates are comparable to any other implants. And this is a fairly recent publication, and this is what our experience has been. And to conclude, this method has revolutionized reconstruction in career facial deformities. Surgery is precise. It makes it easier, good outcomes, operating times are reduced, and there is some cost to VSP, which is offset by reduced operating times and maybe better quality of results. And I think PMMA implants that we manufacture are cheaper than the implants, custom-made implants you get from outside. The PMMA cost implant, the PMMA cost is just about $100, and there is no other implant that can be that cheap. So with that, I'll conclude my talk. Thank you for your attention, please. Thank you for watching! So, thank you Rakesh and then now we will go on to the next presentation. Can I go ahead? Can I go ahead? Yes, please. Okay. Thank you very much Rakesh. Let me go to the first slide. Thank you very much and I am following Rakesh's, Rakesh was talking about the virtual surgical planning. I want to follow up with a few of the techniques that has been used in this, you know, his last lecture will be used in my cases also. But generally I would, I would put the purpose of my talk as why, how important are the functional reconstruction in certain areas of the head and neck when you do the head and neck cancer management. See these are some pictures of the defects which in fact has been created by our own surgeons where the patient cannot open the mouth, there is an antigum deformity, there is a maxillary gross defect with a severe trismus and this is another bilateral maxillary defect after maxillectomy. So these are all defects which are common, not very common I would say which you would like to avoid because ultimately the quality of the cure is as good as the quantity of cure we offer in head and neck cancer management. So let me look at the purpose of my talk of functional preservation and rehabilitation in head and neck cancers. I would say there are two specific areas, two distinctly different areas in head and neck, oral cavity and oral pharynx where chewing, speech and swallowing are important functions that are affected and larynx and laryngopharynx which is where the swallowing and speech is also equally important whereas the other component is nasal breathing because of course you all know that laryngectomy causes a cessation of nasal breathing. So in this talk because of the paucity of time I would concentrate on the functional preservation, preservation, rehabilitation of oral cavity and oral pharynx where there are three functions which are important speech, swallowing and chewing. So let me go into the speech and swallowing part where the tongue resection is the one which affects the speech and swallowing most after head and neck cancer management. And speech is affected by the site of the defect and size of the defect. Let me go into the site of defect. The site of defect is commonest is the lateral tongue where speech is affected. This is the common sort of cancer which we see in our parts of the country where you need to do a resection which can affect the speech. The next one is if you have a lateral defect it can go on to the tip. It has got again the speech is the maximally affected in these group of patients after the resection. The next group is one where the tumor goes into the sulcus and you may need to do a marginal mandiblectomy or you may need to just shave it off from here so that you know your sulcus has to be removed and here the speech and swallowing is equally affected because the sulcus through which the foot bolus passes on to the oropharynx is affected. So I would say the last just before that is the base tongue. See if a tumor goes back to the base tongue again speech and swallowing are affected because the bulk is needed here. So if you summarize these defects the lateral tongue it is speech is affected and reconstruction is based on the size. In the lateral tongue extending the tip reconstruction is based on the size but avoid putting flaps on this tip area allow it to be mobile as much as possible and in case of base you have to add bulk and in case of the sulcus try to reconstruct the sulcus. Size of the defect matters less than half less than one third one third to half and subtotal and total are the way we will divide for reconstructive purposes less than one third everybody agrees that no reconstruction is needed but whereas if it is one third to half it is controversial and most of the people would reconstruct and then the methods of reconstruction are radial forearm lateral arm ALT medial sural or if it is a pedicle flap it is infrahed submental nasolabial and fam and submental flap is a very good flap and we have been using it quite frequently because of the you know it is a regional flap it is very quick to do. The only problem is that your case selection is important it is very good in females again elderly females where the solid food she is speaking in Malayalam but it is very clear the infrahed area again is a very quick flap which you can do to line the tongue. Fam flap is another flap which has been used of late by some people it gives an excellent sort of contour and color and mucosa like you know it is a mucosa in fact but the problem is this donor side you have to bring the fam down into the under the mandible and take it under the mandible to the tongue. So it is a bit laborious process but it is a very good flap. Lateral arm is another free flap which is very very useful flap and we like it very good in our unit because the quality of the skin and fat is excellent you can see this lady who talks. Again she is talking in Malayalam but it is very clear sort of the words she can speak with the flap. Gastro mental flap it is something which has been described by has been used by us and it is described by one of my colleague. See again it gives excellent moist mucosa. This is the gastro mental flap which can withstand the radiation effects and then produce a moist mucosa after that and it can be harvested by laparoscopy with least donor sites and this is the appearance after radiation it retains the mucosal gland integrity as well as remains moist. The area where you have to be cautious in reconstructing the tongue is the tongue lesions which extend into the sulcus. Here the sulcus has to be respected and reconstructed. This is an ALT flap where this goes to the tongue and this is to the sulcus where it is thinned and it goes down and this picture is another radial forearm where it can be tucked in into the sulcus so that there is a sulcus which allows the tongue to move as well as allows the foot bolus to pass through if possible. Subtotal and total is very difficult. Let me let me go back without the sound. Now this is a ALT flap is good in most of the situations which it provides bulk but the problem is the clarity of the speech and then it can sink down after some time if you don't support it. You can see this fantastic I would say the speech you can get with a simple ALT flap. Hi, my name is Raj Paulus, I am 37 years of age, I belong to Kerala and I am working in Bangalore with International Bank as a network security. Hi, my name is Raj Paulus. The key in using any of the soft tissue flaps for total tongue reconstruction is to prevent them from sinking down and that is by either using a rectus flap or an ALT flap with the muscle and you put the muscle as a tight diaphragm between the floor of mouth and the between the you know hitching it to the mandible on either side by drill holes. So that keeps the ALT or rectus tissue rectus tissue up into the palatoblossal contact as well as keep it keeps its mobility. Now coming to the dynamic muscle transfers they have been described and then what we have done was to use a use a gracilis with a momentum like this is a this is the gastro metal flap, this is the gracilis flap which again gives a good mobility and good speech. Lastly in tongue if you want to be very very good in preserving the function and providing good good sort of thing is using a robotic assisted base tongue resection avoiding the mandibulotomy which was reported by one of one of my team members you this is a patient who had a you had a lesion like that and this was robotic assisted exercise without mandibulotomy and this the lesion this is the lesion taken out radial forearm flap put with excellent sort of results in swallowing and speech. Now coming to the last part which is the chewing in oral cavity and oral pharynx see in case of what do you need for chewing is you know two teeth healthy teeth which occludes and which can you know which can bite upon. In a dented mandible you preserve that form and function by doing an IMF and pre-plating like this is very easy whereas in cases where it is it is not possible you can use in a expanded mandible like this pre-plating is not possible. Here what you can do is to do the mirror imaging with Rakesh showed you before and get the mandible to the opposite side and plate it plate this mandible and use this as the template for your fibula to be put in and this is a patient who had a similar sort of reconstruction with a with a reasonable good result. If it is a retaining the height is very important for implant placement you can use a double barreling like this you can use a DCIA flap like this where the height is the best with DCIA and then the implant placeability is the best or recently what we have done is to use the patient specific implant manufactured in India itself which gives a higher platform for your fibula to be placed which allows a good contour the PSP gives a good contour and the fibula being placed high gives a better implantability of the bone. Managing the absent condyle you can have a gap arthroplasty like this excellent result but sometimes what happens in a majority of the patient there is some amount of drift when you open the mouth and then it is not good and instead of that you can use a custom made or readily available stock joint along with your fibula like this you have to plan it meticulously with the STL models like this and this is the patient who had a this is the glenoid component and this is the fibula with the implant and you can see it works exactly like your normal joint and it can be used in cases where it is a benign case where there is no radiation needed. Joint absence of joint like this in a child is a problem you have to provide a you know growing growing and this is a raging controversy I am sure there will be lot of discussions among all the people regarding what is the best way to provide a growing joint. One which you we use was a latissimus dorsi with the serratus and rib I will just take you through the picture 1 year 8 years post-op and but when you see your rib has grown but it is very thin and it cannot accept implant. So what we did was to put augment that with the iliac crest graft and put implants and finally got this picture. Using dentition as inverse planning see this bilateral maxillectomy again exactly same what Rakesh did you use the mandible as the base thing and then you fabricate your maxilla on that and then you can place implants like that. Lastly two cases which I want to discuss is a is a you know usually some amount of interest in a way because of their grossness and the anatomical distortion they had when they presented to us. This was an osteosarcoma of the mandible right hemimandiblectomy 10 years back recurrence treated 6 years back and currently came like this but PET scan shows absolutely localized disease and this is him you know he could not eat and this is a huge tumour. Where to anchor the neomandible there is no mandible and how to address the mouth opening and closing how to get the lip competence everything was a big problem. What we used was to have a fibula like this and use the skin paddle and we used two of the plates to anchor it to the wafer and the maxilla anteriorly and one into the temporal area and another in the temporal area for the temporary basis and what we did was to remove it later on so that once it a flap had settled and later on took a sling of muscle from this is the patient immediately after reconstruction and then you can see the patient immediately after with a lip incompetence this is after sling correction coming into the temporalis and this is him now I will show you this video. So he can drink now and he bites somehow or other these patients do very well even with eating. Lastly this is a this is a 16 year old patient with a giant ossifying fibroma like this he was detected to have this tumour and he was living with this for several years his father was no more deserted by mother he was working in a is living in a tribal village in North India where there is no medical facilities available it was brought to us by some charitable organizations and then this is his video you can see that how he opens the mouth the entire upper jaw is affected and you can see the just watch his eyes you can see his eyes moving functioning eyes. Now this is the this is the tumour now again this was a huge problem how you do not have an anatomical landmark so what we did exactly same what Rajesh said orbit mirror image intact mandible use as the mirror reference point for inverse planning the question was can the eye be saved how do you support and this was 4.8 kilogram of solid bone and this is a picture after your resection and these were the reconstructive challenges we had we used the fibula and then we use the fibula to contour this and then we used it again to support the nose also finally getting this picture at the end of the end of the surgery and this was him when he was going to be discharged and then this was him when he was being discharged from the hospital starting back to his social life and as reported currently he is now taking a volunteer job in that tribal village to help the other people in their medical matters. So thank you very much I have been taking you through some aspects of functional reconstructions of the head and neck cancers. I know that I have not covered a lot of things especially the laryngeal part laryngopharyngeal part where a lot of things have been happening regarding preservation of the larynx, laryngeal functions, preservation of the swallowing functions in there but lack of time doesn't permit me to elaborate on that. Thank you very much. Thank you Dr. Subramanian. So it was a really nice talk. We had very good talks from Dr. Akesh Kazanchi and Dr. Subramanian and both of them spoke very well on the complex reconstructions in the head and neck region, one on the cancer and one on the other one and I must tell that he has a unique distinction of being head of the department of head and neck oncology as well as the plastic surgery at Amrita Institute and they are doing a wonderful work there. And now the next speaker we have is another very dynamic plastic surgeon from the western India and he runs his own plastic surgery hospital Dr. Rajendra Nethe and he will be talking on nuances in soft tissue reconstruction of foot and ankle. So Dr. Rajendra Nethe is an excellent microvascular surgeon and is doing very challenging surgeries and we are going to listen to him. Nethe please share your slides. Can you see my presentation, Ravindra? Yeah, Rajan, we can see it. Please carry on. Okay. Good evening, delegates. First of all, let me thank ASPS and APSI for organizing this webinar and inviting me to talk on nuances in soft tissue reconstruction of foot and ankle. So if you talk about foot trauma, it is a very common injury in India, especially when people work barefooted at the workplace. And as the injuries affect the mobility of a person, they can have significant adverse impact on patient's day-to-day life. It can reduce the productive capacity of a person. But however, the foot trauma is less discussed and less published. So aim of treatment in foot trauma is to achieve a normal gait, that is the functional capacity of the foot. And that is achieved through bony stability and joint mobility and durable and aesthetically good soft tissue cover. So we achieve this through objectives like stable bony architecture to achieve normal anatomic foot alignment and maintain the arches of foot. Good range of motion at the ankle joint, stable and durable soft tissue cover, aesthetically acceptable outcome. And one of the criteria is patient should be able to wear the same size of footwear that of opposite foot after you do a reconstruction. And this is the physical therapy almost every patient should receive to achieve a normal gait. So at our institute, we classify the foot injuries in little different manner. So it is important for a therapeutic intervention. So we divide it as single component trauma or a multiple component trauma. A single component trauma has either a skin eversion or degloving or a tendon injury or bony injury. And two of them can be together in some patients. These are relatively easy to manage and do not lead to long-term sequelae. However, some patients may have delayed skin necrosis which may add to complexity as they need a flap cover. Whereas in multiple component trauma or a complex trauma, there is bony injury as well as soft tissue injury or maybe associated vascular injury. These are either open or closed and if not managed properly can lead to unfavorable clinical outcome. Some of these patients may need emergent management due to vascular injury or major skeletal trauma. However, we treat all the trauma patients on emergency basis. At least day one, the debridement is done so that it can facilitate the wound coverage and bony fixation and it avoids the infections which occur in these patients. So on day one, you have to take two decisions. One is whether to salvage or amputate and it depends on whether patient can have the painless and functional foot. Or whether you want to do a single stage or a multi-stage reconstruction. Though it is a soft tissue cover, I will talk about the ankle joint restoration because it is one of the most important thing in foot and ankle reconstruction. This was a trauma patient with dislocation of the ankle and a fracture dislocation. It is very important that you fix it properly and achieve a soft tissue cover properly. So this was fixed temporarily with KYS. After vascular stabilization, it was operated for bony fixation. You have to achieve a normal bony mortise and then you do a flap cover to achieve a good range of ankle motion. Another patient with loss of medial malleolus and in this patient, if you can't restore the medial malleolus, then you will have unstable ankle. So we reconstructed the medial malleolus with iliac crest bone graft with having extension of the bicep femoris tendon to reconstruct the deltoid ligament. And it was covered with free muscle flap with skin graft. I used to do a lot of flat dorsal flap for extensive defect that time. This was case done almost 15 years back. This was 8 years follow up of the patient and you can see a good restoration of the foot. And he has a good ankle mobility as well as stability. It is one of the very important factors when you deal with foot and ankle trauma. Sometimes you may need ankle arthrodesis if you want to achieve a painless functional joint. The other option is ankle joint replacement but we are not using any joint replacements. Another point I will emphasize in foot trauma is prevention of tendoacles contracture. It is very common occurrence after ankle and foot trauma and it is easily preventable by surgeons. So this was a patient which we received with a small defect on the tendoacles region but her ankle was stiff. This was a girl in a marriageable age group. And we did the popular flap to cover this trauma but you can see the stiffness of ankle was still there. They were not ready for tendoacles lengthening. So they realized later that it requires a lengthening and we did lengthening. We did lengthening of the tendon as well as ankle arthrodesis. And we could achieve a good movement in the ankle joint but then this flap was insufficient. So we excised that flap and covered it with the parascapular flap. Being a young girl, the defect is a linear scar after this closure and you can achieve a good result. Aesthetically good looking and good ankle mobility in her foot. So we prevented by using the external fixator. This is again a patient which we received like this with the heel defect. So this ankle was stiff in plantar flexion. So initially when we put the fixator, the ankle position was like this. And within a few days, we could achieve a good 90 degree. And then we reconstructed the heel with the gracilis flap with the skin graft. And you can see a good contour of the heel restoration almost equal to the opposite side of the foot. So they can bear the same footwear. It is essential to talk about fractures in the foot. It is important to restore the arches of the foot and med bearing areas. Otherwise the problems are more. And when you fix the bone, we follow the protocol of first the ankle stabilization and then bony fixation from proximal to distal. It has to be stable bone fixation and you may require a joint fusion if necessary. You can use internal or external fixation or a hybrid fixation. This was a young patient with a foot trauma, motorcycle injury and you can see a big soft tissue defect with dislocation of his navicular bone. So we place everything in and we use the hybrid fixation with KYS and the external fixator. And this was just before the debridement and after the debridement. We stabilize the foot with the external fixator as well as the KYS. And this was the resultant defect which was managed with the serial back dressings. And with negative pressure wound therapy, once the wound was improved, we analyzed it again. Because the non-med bearing area was requiring the cover, we used the Integra. And on the Integra, then we added the skin graft and you can see an excellent cover which did not need. Initially we were planning to do a flap but we could simply avoid a flap by using Integra and a skin graft. And here is an excellent restoration of the foot. This was a very early video and he was walking well. I am sure he will do very well over the time. When we talk about soft tissue cover in foot defect, size is very important. We know, all of us know Hidalgo and Shah classification. I will not go into theory. It depends on the tissue requirement, what type of tissue you require. And again, I find it that the choice of flap by surgeon is also important in these patients. In the foot being the most distal region of the body, local tissues for reconstruction are less. So moderate and larger size defect will almost need a regional or a distal flap. However, we are not very happy with regional flaps. They are distally based with retrograde circulation and we find almost 15-20% of patients giving problems. So the distal flaps need a micro surgical expertise. The safe way of doing cross leg or cross thigh flaps are to be condemned in today's era. Though they have role in rare instances and we still sometimes use it but very rare. So our preference because of these reasons goes for a free microvascular flaps. And there are definite advantages like minimal scarring in the surgical area which I will demonstrate and minimal donor site morbidity as we plan different flaps. So this was a heel avulsion injury patient. There is a young child, a 6 year old girl and we have used the parascopular flap. Here we use the random any perforator which we get in the parascopular area and you can have linear closure and usually it is in the normally hidden area by the clothes. So we use the prostratable vessels as the recipient vessels and you can see a final result, a well contoured heel area, prostrate heel area and there is no added surgical scars in the local area. So if we compare to the local flaps or local regional flap, this is the very well executed sural artery flap, very thin flap but then there is addition of the scar and graft almost extending up to the popliteal region. This is another patient treated with the prophyla flap but you can see a grafted area and extensive scarring in the local area. Whereas if you use a free microvascular flap, the addition of the scar is not there on the leg and that is why we prefer a free flap. Over the years we have changed our philosophy from going to parascopular flap to free groin flap to a skip flap so that the donor site morbidity is also much less. This was a 21-year-old female. She had a fall from second floor. She jumped and then she had multiple fractures which were managed with plate and screw fixation. The calcaneum was also plated and the right foot calcaneum was fixed with KYS. But on the left side she had a small defect which needed a young girl in a manageable age group so we did a free groin flap and you can see a restoration of the posterior area. This is her video. Initially she had limp but now she walks very well. We get many patients like this with the lateral heel defects wherein they have a defect on the lateral side of the heel. When we reconstruct this, the defect is on the lateral side and the recipient vestibule vessels are on the medial side. Either we have to pass the pedicle anterior to the endoachelis or over the endoachelis which is prone for compression. So what we started using is lateral calcaneal vessels as the recipient vessels. These artery and one or two venacometers are behind the lateral malleolus and diameter of 0.9 to 1.8 mm distally and proximally it is almost 1.5 to 2 mm. So this is the patient with lateral defect. So you take the exploratory incision, you see the venacomitans initially and then you see the arteries also. This is again a parascapular flap we were using. There is a lot of venous communication in this area so you can take any of the veins of the tributary of the short syphilis and this is the reconstruction. So we don't need to go on the medial side with no addition of excess scars. When we talk about dorsum of the foot in a trauma, these are the patients with fractures of the metatarsals and the tarsal area. So they were fixed with the KYS and we use very often gracilis with skin graft. I feel the gracilis muscle thins out very well if you spread it properly and after atrophy it gives an excellent contour to the foot. So you can see a skin graft after maturity it does very well. But in some patients like this patient, 6 year old male treated with the similar gracilis but then delayed healing in this patient and sometimes some inadequate debridement they lead to eczema especially on the grafted area, especially on the lower limb we find this problem. So we are just evaluating whether Integra can avoid these eczema changes. We started using Integra on these patients and these are the first patients which I showed you and I think Integra can solve most of the problems of eczema if we put grafts in the foot area. This was a 10 year old male with road traffic accident, again a small boy but he had extensive trauma going up to the lower third of the foot. So in such cases debridement is very crucial, you have to get rid of all the necrotic tissue and the bone debridement also has to be radical so that there are no osteomyelitic changes. And this was covered with anterolateral thigh flap which is one of the workhorse flaps in our unit now. And you can see when the flap contours it does very well. One sitting of thinning and you can see very well settled flap with excellent contour. So he can use the same footwear. Another patient with 34 years with road traffic accident you can see almost subtotal amputation of the lateral part of the foot. If you evaluate properly and join them back you can restore a good foot. So this is after the debridement and skeletal fixation with one wag dressing. And this is again after repeat debridement and the second toe had devascularized so we removed it and reconstructed the intermetatarsal ligament. And you can see anterolateral thigh flap and this is the patient after one and a half year after follow-up is done very well. So when we analyze the choice of the recipient muscles for dorsal defect we tend to use posterior tibial artery. It is preferable. We feel that most of the trauma these patients go into plantar flexion and the retraction on the dorsal spadius pedicle and there are minute trauma to the vessels which will lead to spasm and will give a problem to the free flap. So we feel dorsal spadius or using anterior tibial in the ankle region are little dangerous and we don't use it. We use the vena comitantes and superficial veins of the tibia tree of the superficial veins. Not the main veins because long syphonous and short syphonous we feel they are very thick walled and prone to spasm and give rise to problem. So vena comitantes are best in the leg to use or the tibia tree of the short softness or a long softness. When we talk about the heel defect, we had a policy of using the lat dorsi initially. So this presents a philosophy which changed over the time. But then lat dorsi is a little bulky muscle, especially in the proximal part and that bulk cannot be reduced with anything. So we started using gracilis muscle for this thing because it can be contoured very well. It can be spread if you cut the epimysium and this is the axial fixator which we use to stabilize the ankle. Similar patient which I showed you initially and if you contour it well, you can really get a good result in heel reconstruction and patient can use the same size of footwear of the opposite side and their problems are less. But when we have circumferential foot injury, there is tissue loss in all four zones. So this is the patient which we received late in this condition. So we debrided everything. There was loss of heel and loss of soft tissues on the dorsum of the foot and the ankle region. So you debride it well and after two serial back dressings, she was in this condition. So what we do is we do it reconstructed in two stages wherein the non-critical areas in the dorsum of the foot and the lateral and medial are covered with the skin graft and in second stage, once the graft is matured, we do heel reconstruction using the gracilis flap and we find that this technique gives the best of the result in terms of reconstruction of very well contoured heel. Sometimes you get a de-gluing of the foot and he had brought his foot but it was almost 15-20 hours after the trauma so we did not try to replant it. Patient was also bad. He had a chest trauma so we used the graft initially. But then we were thinking of reconstruction and we used the lat dorsi flap to wrap around this foot and this is the reconstruction. He is still in touch with us after 20 years of reconstruction and he is doing very well. But then foot de-gluing you have to remember that you have to amputate the distal phalanx of the great toe and two distal phalanges of the other toes so that they don't poke into the foot when the patient walks. It is similar to a hand injury where in de-gluing the finger injuries or all the finger injuries, we have to amputate the distal phalanx, distal to the insertion of the FDP so that it becomes more functional. So to summarize, foot and ankle trauma needs more attention to avoid permanent disability and achieve functional result. I feel the ankle joint restoration and prevention of T-contracture is very crucial in management of foot trauma. And as we prefer free flaps, we feel the free flaps achieve better aesthetic results and functional results than the local regional flaps. So if you achieve all these objectives, definitely we improve the patient care and the functional results are better. Thank you very much. Thank you, Nete. So I think it was a very nice presentation, you know, telling us about the nuances in the soft tissue reconstruction of the foot and ankle. So I think with these, we finish all the three talks in the webinar. And now we can, I think, have some questions and Dr. Raja, you would like to take up some questions? Yeah, thank you so much. We'll start off with the questions to Dr. Rakesh, which was the first presentation. Rakesh, I find a question in the chat box, I think probably they are referring to the girl who we are nicely reconciled with the geneoplasty. So they asked us, is there any specific technique that you used in the choice and how did you do the geneoplasty? That was the question. That was a simple, I think there was a computer picture of that. There was a simple sliding geneoplasty. We did a horizontal mandibular cut out there, which was planned with a model. It was virtually planned. And then we just moved it from left to right about 1.5 centimeters and fixed it in that position. There was no advancement or setback. There may be some on the edges, some burying was done to just round up. So that was all that was required. That was the first case that I've shown with geneoplasty. I think there was one I showed in towards the end, which was an implant geneoplasty, where there was asymmetry, but it needed addition, it also needed augmentation. So we use the implant to augment and also on one side an extra length of that implant was used to correct the asymmetry, which with the implants, which are, you know, manufactured implants, Medpor and others, you know, they are just symmetrical and it's difficult to get them absolutely right and fit to the mandible that was existing. I hope that answers the question. Yeah, that's right. Thanks, Rakesh. And before passing on to Iyer, I just want to ask, you know, in your practice, now that you regularly started using this CAD technique, how much is the average time that has been cut off on your operating time? Hello, Rakesh. Can you hear me? I just asked how much operating time has been cut on by your operating schedule by the use of this technique? I don't know. I mean, we measured it for, you know, for a large experience with free fibula, where we've been cut down about one and a half hours of operating time. But I think for implants and all, we haven't done any measurement. But certainly you think we are just, you know, initially we were checking and cross-checking. But now, as we get more and more experience, we are very sure, you know, it's once we've got the dyes and cutting guides ready, it becomes a no brainer. We just close our eyes and cut, you know, so just be a little careful. So I really don't have any measurements. Certainly, it's fairly significant time, I think. So now I go to Subbu. Subbu, there is a fantastic presentation of massive big tumors being taken out, which are there in the developing countries. There's one question where you say when the whole mandible is excised, when you put in a fibula and when there's no condyle, how much of a mouth opening do they have and are they really able to masticate their foot? Yeah, see the problem is with the absent both condyles is not able to open the mouth. In that case, the problem was to close the mouth because there's no, if you look at it, there are three muscles, temporalis, medial, nothing is there. So in order to, opening mouth is by gravity, it happens. But closing was a difficult thing. So that is where we put static sling and then, in fact, he's not moving the mandible much. Basically, the mandible is staying there as a support for the lip and then it is through the lip and tongue movements, he is, in fact, swallowing. But there is adequate mouth opening there so that he can, you saw that person introducing the biscuit, no, there was a space there and stays there. That's the way. I don't think if there is total mandiblectomy with all the muscles gone, currently there won't be any technique to provide that muscle movement for that. Yeah, that's a good point. It's more than opening the mouth, it's closing the mouth and giving power, that's the problem. You nicely brought it out. Another question is poorly vascularized fibula. I think probably the person who put this question is to find your free flap failure rates in fibula for oral cancers. Yeah, you see, if you say generally 4 to 5% is accepted thing which is most of the, most of the, I would say anything between 96 to 99% is something which is the prevalent sort of thing which reflects in our large series also. But you have to be, see, all this comes with the proper selection of cases. See, if you find a very thick atherosclerotic fibula, when you do it, you, we don't do angiograms as a routine, but when you feel the, then you have to abandon it. You cannot work on a very thick atherosclerotic vessel in the fibula and then expect it to succeed. So your case selection also is important in those cases. Otherwise, I think over the, across the globe, the fibula is a standard and very safe sort of flap. So thank you so much, Sibu, for this wonderful presentation. Now we move on to Rajendra. Very commonly asked question now, what do you, what's the flap that you would prefer for the weight-bearing soul? Yeah, as you must have seen in my presentation, almost always I prefer to use the muscle with the graft. See, there is always one more question, it is there in the chat box about the doing a sensate flap. So I'll compare both of these things because I had done two decades back when I did my MCH, I did a thesis on innervation of the flaps and their impact on the sensation and function. So we had a conclusion that whatever type of flap you do, whether you do a skin flap or a muscle flap with an innervated flap or a non-innervated flap, the quality of sensation what patient gets is only a protective sensation and which is not adequate to avoid ulcerations on the foot. So all these patients will have definitely have ulcerations in the early period of the flap cover. Now, when you compare the skin flaps with the muscle and graft, the skin has a mobile fat and which leads to a wobbling of the flap, especially if it is a thick skin flap cover. Whereas the muscle if you put, it sticks to the calcaneum and on that the graft remains very stable and there is no wobbling of the flap and the wobbling increases the friction in the flap and the ground and that leads to ulceration more. Because in the heel area, the friction is less, the weight-bearing capacity has to be high. Whereas in the forefoot, the friction is more. So that is why I feel that the muscle with graft is a better choice. And when the sensation is not very important, because even in non-sensory flap, you get the same protective sensation, then we don't need to innervate the flap. And that is why I always prefer a muscle with the skin graft. The second important thing what we do in heel cover is we shave off the calcaneal spur, keeping the insertion of the fascia intact, so the deep fascia of the foot, so that the arch of the foot is maintained and the heel is covered where the heel is flat, so that they don't have recurrent ulceration, the incidence is reduced. However, in the long run, we have observed that it mainly depends on the type of care patient takes, using a silicone padding, using a pressure garment, and visualizing his foot, taking care of the foot, cleaning of the foot. And that's what avoids the frequent ulcerations and other problems in the sole reconstruction. Thank you so much, Rayendra. I think perhaps last question will go to our President Rakesh. The question is, how do you fix the bones? What's your preferred technique for fixing the bones in children of the growing age? Okay, before I answer, there's another question just before that, that where do we get our implants from? I think, can I answer that Raja as well, because I think that's important. Okay, so we're not getting implants from anywhere, we are making them on the table intraoperatively. As I'd shown in the video, we do a virtual planning and we plan the implant and a negative of the implant is printed, which is outsourced by a local printer in the town. And we pick it up the day before, sterilize it. And intraoperatively, it's used as a mold or a dye to manufacture the implant with polymethyl methacrylate. I think that's why it really offsets the cost of printing and planning. Because if we had it made from a company, it will cost 10 times as much. I mean, of course, they make titanium as well as metpor. So we are now exclusively using polymethyl methacrylate. I hope that answers your question. And regarding fixing of bones in children, I think the cases I showed of craniosynostosis at the critical areas where the bone is advanced and has to be maintained, for example, at the posterior end of the bendu, we fix it with absorbable plates. But all the non-critical fixations are done with bicarate sutures. Thank you so much, Rakesh. And I also have to take this opportunity on behalf of my co-moderator, Ravi. I thank Dr. Ghazain for his perseverance in bringing up this relationship and all those people at the ASP's office for making this possible. Thank you so much. Over to you, Dr. Yes, thank you. These were great presentations. We're so proud of all of you. It just puts me to shame to see how well you are doing with such a resource-poor country. And you're well ahead of many of the techniques we're using. So congratulations to all of you. And it's great to see these cases. Thank you, Dr. Ghazain. Thank you, Dr. Ghazain. Thank you very much. In fact, we are really delighted to be part of your global partners this year. And this is the first webinar series which we had. And I'm sure with the coming times, this relationship is going to get strengthened further and to be academically fruitful for all of us. And thank you so much. Yes. And the one thing I encourage you all to go on to publication, Rakesh mentioned his series is going to the Journal of Craniofacial Surgery, but anything we can do as ASPS partners to collaborate on these series that are so great to help them get published, let us know. Thank you so much. Thank you. Wonderful. Thank you so much. Thank you. Bye.

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