keystone perforator island flap posterior trunk back reconstruction wide local excision vascular tumor surgical technique postoperative care

"keystone flap" AND trunk

keystone perforator island flap back posterior trunk surgical design diagram

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https://pmc.ncbi.nlm.nih.gov/articles/PMC10846774/

mkdir -p "/tmp/workspace/keystone-back-flap/src" "/tmp/workspace/keystone-back-flap/output" && python - <<'PY' from pathlib import Path p=Path('/tmp/workspace/keystone-back-flap/src/create_deck.py') p.write_text(r'''from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.dml.color import RGBColor from pptx.enum.dml import MSO_THEME_COLOR from pptx.enum.shapes import MSO_AUTO_SHAPE_TYPE OUT='/tmp/workspace/keystone-back-flap/output/Keystone_Flap_Back_Vascular_Tumor_Conference.pptx' prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) blank=prs.slide_layouts[6] # colors NAVY=RGBColor(15,37,57); TEAL=RGBColor(0,133,137); AQUA=RGBColor(104,205,202); CORAL=RGBColor(220,91,74); GOLD=RGBColor(235,177,55); PALE=RGBColor(239,246,246); GREY=RGBColor(77,91,100); LIGHT=RGBColor(248,250,250); WHITE=RGBColor(255,255,255); RED=RGBColor(170,45,45); GREEN=RGBColor(47,129,92) def fill(shape,c): shape.fill.solid(); shape.fill.fore_color.rgb=c def line(shape,c,w=1): shape.line.color.rgb=c; shape.line.width=Pt(w) def rect(sl,x,y,w,h,c,rad=False,lc=None): s=sl.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if rad else MSO_SHAPE.RECTANGLE, Inches(x),Inches(y),Inches(w),Inches(h)); fill(s,c); line(s,lc if lc else c,0.8); return s def text(sl,x,y,w,h,txt,size=18,color=NAVY,bold=False,align=PP_ALIGN.LEFT, font='Aptos', valign=MSO_ANCHOR.TOP): tb=sl.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=tb.text_frame; tf.clear(); tf.word_wrap=True; tf.margin_left=Inches(.05);tf.margin_right=Inches(.05);tf.margin_top=Inches(.03);tf.margin_bottom=Inches(.03);tf.vertical_anchor=valign for j,para in enumerate(txt.split('\n')): p=tf.paragraphs[0] if j==0 else tf.add_paragraph(); p.text=para;p.alignment=align;p.space_after=Pt(4) for r in p.runs: r.font.name=font;r.font.size=Pt(size);r.font.bold=bold;r.font.color.rgb=color return tb def bullet(sl,x,y,w,h,items,size=17,color=GREY): tb=sl.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=Inches(.05) for i,item in enumerate(items): p=tf.paragraphs[0] if i==0 else tf.add_paragraph();p.text=item;p.level=0;p.font.size=Pt(size);p.font.name='Aptos';p.font.color.rgb=color;p.space_after=Pt(7);p.bullet=True return tb def title(sl,t,sub=None,n=None): rect(sl,0,0,13.333,.18,TEAL); text(sl,.55,.35,11.8,.5,t,28,NAVY,True) if sub:text(sl,.57,.86,11.5,.35,sub,12,TEAL,False) if n is not None: text(sl,12.2,.43,.6,.3,f'{n:02}',11,TEAL,True,PP_ALIGN.RIGHT) def foot(sl,txt='Educational conference template - adapt to pathology, imaging, and institutional protocol'): rect(sl,.55,7.12,12.2,.015,RGBColor(210,224,224));text(sl,.57,7.18,11.7,.18,txt,8,GREY) def add_notes(sl,txt): try: sl.notes_slide.notes_text_frame.text=txt except: pass def chip(sl,x,y,w,label,c=TEAL): rect(sl,x,y,w,.33,c,True);text(sl,x+.05,y+.04,w-.1,.2,label,10,WHITE,True,PP_ALIGN.CENTER) def connector(sl,x1,y1,x2,y2,c=TEAL,w=2): l=sl.shapes.add_connector(MSO_CONNECTOR.STRAIGHT, Inches(x1),Inches(y1),Inches(x2),Inches(y2));line(l,c,w) # 1 s=prs.slides.add_slide(blank);rect(s,0,0,13.333,7.5,NAVY);rect(s,0,0,13.333,.22,TEAL) text(s,.7,.85,8.8,.8,'Wide Local Excision +\nKeystone Perforator Island Flap',31,WHITE,True) text(s,.74,2.45,7.6,.45,'Posterior trunk vascular tumor reconstruction',18,AQUA,False) # abstract back silhouette / lesion / flap rect(s,9.15,.7,3.25,5.85,RGBColor(25,57,75),True) # central ellipse el=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(10.22),Inches(2.3),Inches(1.05),Inches(1.55));fill(el,CORAL);line(el,WHITE,1) # keystone outline arcs approximated for y in [1.55,3.95]: a=s.shapes.add_shape(MSO_SHAPE.ARC,Inches(9.55),Inches(y),Inches(2.5),Inches(1.25));a.rotation=0; a.fill.background();line(a,AQUA,2.5) text(s,.75,5.85,7.8,.4,'10-minute conference presentation',15,WHITE,True) text(s,.75,6.35,7.5,.32,'Presenter: ____________________ Institution: ____________________',12,RGBColor(200,220,224)) add_notes(s,'Open with the reconstructive problem: oncologic clearance must not be compromised by closure. This deck describes a posterior trunk workflow; replace the diagnosis and clinical images with your own case material.') #2 roadmap s=prs.slides.add_slide(blank);title(s,'Clinical question and roadmap','How to obtain oncologic clearance while delivering durable posterior-trunk coverage',2) text(s,.65,1.45,3.5,.55,'Clinical question',18,TEAL,True); text(s,.65,2.0,3.35,1.25,'After wide excision of a back vascular tumor, when is a keystone flap appropriate and how is it planned, raised, and monitored?',20,NAVY,True) steps=[('01','Oncologic plan','Diagnosis, staging, margins'),('02','Defect analysis','Site, depth, size, tension'),('03','Flap design','Perforators + laxity'),('04','Execution','Excision, release, advance'),('05','Recovery','Off-load, surveillance, pathology')] for i,(no,hd,bd) in enumerate(steps): x=4.5+i*1.7; rect(s,x,1.8,1.38,2.9,PALE,True,RGBColor(196,220,220)); chip(s,x+.18,2.05,1.0,no);text(s,x+.12,2.62,1.15,.45,hd,14,NAVY,True,PP_ALIGN.CENTER);text(s,x+.12,3.35,1.15,.6,bd,11,GREY,False,PP_ALIGN.CENTER) if i<4: connector(s,x+1.38,3.25,x+1.65,3.25,AQUA,2) rect(s,.65,5.3,12.0,.92,RGBColor(255,247,233),True,RGBColor(244,213,153));text(s,.88,5.54,11.5,.35,'Scope note: “vascular tumor” is not a single diagnosis. Margin, nodal work-up, radiation, and systemic therapy depend on final pathology and multidisciplinary discussion.',15,RED,True) foot(s);add_notes(s,'Spend about 40 seconds. State that the reconstructive technique is generalizable, but cancer treatment details must be individualized to histology, grade, and stage.') #3 assessment s=prs.slides.add_slide(blank);title(s,'Preoperative work-up: plan the cancer and the reconstruction','Two plans must be made before the first incision',3) for x,hd,items,c in [(0.65,'Tumor / patient',['Histology review ± repeat biopsy if uncertainty','Cross-sectional imaging for deep extension and relation to fascia/muscle','Stage appropriately; discuss in sarcoma/vascular anomalies MDT','Optimize anemia, nutrition, glycemia; stop nicotine'],TEAL),(6.9,'Defect / flap',['Examine skin laxity in prone position','Map prior scars, radiation field, infection, and adjacent lesions','Anticipate excision depth: dermis, subcutis, fascia, muscle','Choose unilateral, bilateral, or alternative reconstruction before excision'],CORAL)]: rect(s,x,1.45,5.75,4.9,LIGHT,True,RGBColor(213,225,225));chip(s,x+.3,1.75,1.8,hd,c);bullet(s,x+.38,2.35,5.05,3.4,items,17) text(s,.75,6.57,11.8,.3,'Consent: bleeding, infection, seroma/hematoma, delayed healing, dehiscence, partial necrosis, scar and possible re-operation / graft / alternate flap.',12,RED,False) foot(s);add_notes(s,'Imaging has two aims: establish extent for safe resection and anticipate the final defect. Markings must be performed with the patient positioned as for surgery because posterior-trunk skin shifts substantially.') #4 selection s=prs.slides.add_slide(blank);title(s,'Why a keystone flap?','A local, multiperforator fasciocutaneous advancement flap',4) text(s,.65,1.35,5.3,.42,'Mechanism',19,TEAL,True);bullet(s,.7,1.85,5.25,2.3,['Curvilinear trapezoid adjacent to the defect','Conceptually two conjoined V-Y advancement flaps','Perforators are preserved within the central tissue bridge','“Like-with-like” skin: color, thickness, sensibility and contour'],17) text(s,.65,4.55,5.3,.42,'Best suited when',19,TEAL,True);bullet(s,.7,5.0,5.35,1.3,['Moderate posterior-trunk defect with adjacent mobile tissue','No need for a thin free flap or large-volume replacement'],16) # comparison rect(s,6.4,1.35,6.15,4.95,PALE,True,RGBColor(205,225,225));text(s,6.75,1.65,5.35,.35,'Decision checkpoints',19,NAVY,True) rows=[('Proceed','Clean, vascular local skin; manageable tension'),('Modify','High tension: add fascial release, larger flap or double keystone'),('Avoid / escalate','Irradiated/infected scar, exposed hardware or large 3-D defect: consider other local/regional or free tissue')] for i,(a,b) in enumerate(rows): y=2.25+i*1.15; chip(s,6.75,y,1.25,a, GREEN if i==0 else (GOLD if i==1 else CORAL));text(s,8.18,y+.02,3.95,.55,b,14,GREY,False) foot(s,'KPIF literature supports technical simplicity, but trunk complications remain clinically relevant.');add_notes(s,'The keystone is not a rescue closure for an unresectable or contaminated field. Do not trade tumor margins for an easier flap. In difficult fields, have an escalation option ready.') #5 mark s=prs.slides.add_slide(blank);title(s,'Marking and flap design','Design the flap after estimating the true excision defect',5) # diagram rect(s,.7,1.35,6.1,4.95,RGBColor(247,250,250),True,RGBColor(210,224,224));text(s,.95,1.6,5.5,.3,'Schematic: unilateral type IIa-style keystone',16,TEAL,True) # defect ellipse e=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(2.7),Inches(2.55),Inches(1.15),Inches(2.2));fill(e,RGBColor(255,229,223));line(e,CORAL,2);text(s,2.82,3.42,.9,.32,'DEFECT',12,RED,True,PP_ALIGN.CENTER) # flap trapezoid-ish via freeform impossible use parallelogram f=s.shapes.add_shape(MSO_SHAPE.PARALLELOGRAM,Inches(4.15),Inches(2.18),Inches(1.85),Inches(2.95));fill(f,RGBColor(215,244,242));line(f,TEAL,2);text(s,4.55,3.42,1.05,.35,'FLAP',13,TEAL,True,PP_ALIGN.CENTER) connector(s,3.9,3.65,4.25,3.65,CORAL,2) # arrows movement connector(s,5.65,3.3,4.05,3.3,TEAL,3);connector(s,5.65,4.05,4.05,4.05,TEAL,3) for x,y,num,lab in [(1.05,2.1,'1','Ellipse / defect long axis'),(1.05,3.05,'2','Flap long axis parallel to defect'),(1.05,4.0,'3','Flap width approximately defect width'),(1.05,4.95,'4','Curvilinear limbs meet defect at ~90°')]: chip(s,x,y,.35,num,CORAL);text(s,x+.48,y+.02,1.1,.28,lab,11,GREY) # plan checks rect(s,7.25,1.35,5.35,4.95,PALE,True,RGBColor(205,225,225));text(s,7.58,1.7,4.6,.35,'Marking checklist',18,NAVY,True);bullet(s,7.55,2.28,4.65,3.4,['Mark lesion and planned oncologic margin before infiltration','Use Doppler selectively if anatomy/scar/radiation makes perforator location uncertain','Mark both V-Y ends and anticipated line of maximal tension','Confirm pinch test and backup plan after positioning','Photograph / record dimensions for the operative note'],16) foot(s);add_notes(s,'Show the defect and flap relationship. The wording “width approximately the defect width” is a practical starting point, not a rigid ratio. Final design depends on mobility and defect depth.') #6 operative technique s=prs.slides.add_slide(blank);title(s,'Operative technique: stepwise','Key principles: hemostasis, perforator preservation, tension reduction',6) steps=[('1','Position & prep','Prone with pressure-point protection. Antibiotic prophylaxis per protocol; wide prep permits extension.'),('2','Oncologic resection','Perform WLE to planned deep plane. Orient specimen, document dimensions; request frozen section only when it will change management.'),('3','Design after defect','Reassess defect, redraw if needed. Incise flap outline through skin and subcutis.'),('4','Release & elevate','Divide deep fascia along outer curvilinear border for type IIa where needed. Undermine judiciously; retain central perforator-bearing tissue.'),('5','Advance & inset','Gently advance, close V-Y limbs first to recruit laxity. Eliminate dead space; use layered, low-tension closure.'),('6','Dress & protect','Assess capillary refill/edge color. Consider closed-suction drain when dead space is meaningful; apply non-compressive dressing.')] for i,(num,hd,bd) in enumerate(steps): col=i%2; row=i//2; x=.65+col*6.25;y=1.35+row*1.75 rect(s,x,y,5.8,1.35,LIGHT,True,RGBColor(214,226,226));chip(s,x+.2,y+.2,.46,num,TEAL);text(s,x+.82,y+.18,4.55,.28,hd,15,NAVY,True);text(s,x+.82,y+.57,4.62,.6,bd,12,GREY) foot(s);add_notes(s,'The central point: do not skeletonize a single perforator. This is a multiperforator flap. Avoid over-thinning, twisting or aggressive undermining that compromises the vascular contribution.') #7 closure s=prs.slides.add_slide(blank);title(s,'Inset, drain strategy and tension control','Most avoidable problems arise from dead space or excessive closure tension',7) # three blocks for i,(hd,items,c) in enumerate([('Closure sequence',['Deep dermal / fascial tacking only if needed','Close V-Y ends to gain advancement','Then inset central edge with layered, absorbable support'],TEAL),('Dead space',['Meticulous hemostasis before closure','Quilt or progressive-tension sutures when appropriate','Closed suction drain for significant cavity or oozing'],CORAL),('Tension rescue',['Wider fascial release, further V-Y advancement','Consider double keystone / alternate flap','Never force a blanched or congested inset'],GOLD)]): x=.65+i*4.18;rect(s,x,1.55,3.78,4.65,PALE,True,RGBColor(210,224,224));chip(s,x+.35,1.88,1.85,hd,c);bullet(s,x+.33,2.55,3.1,2.95,items,15) text(s,.8,6.5,11.8,.3,'Before leaving theatre: confirm hemostasis, no focal pressure, a viable flap edge, drain security, and a written positioning / dressing plan.',13,RED,True) foot(s);add_notes(s,'Use the closure sequence as a mental checklist. If closure requires excessive traction, revise the plan. A small partial dehiscence is preferable to flap compromise, but forced tension can lead to both.') #8 postop s=prs.slides.add_slide(blank);title(s,'Postoperative care and surveillance','Protect the flap in the first days, then protect the oncologic result long-term',8) # timeline connector(s,1.2,2.6,12.0,2.6,AQUA,3) items=[('0-24 h','Flap color, warmth, capillary refill; bleeding / hematoma; analgesia; avoid direct pressure'),('POD 1-3','Daily wound and drain assessment; mobilize with pressure avoidance; watch for congestion, infection, seroma'),('Week 1-2','Dressing review; drain removal guided by output and cavity; remove sutures according to tension/site'),('Weeks 2-6','Limit shear and strenuous lifting; assess dehiscence and scar; final histology review and MDT plan'),('Long term','Tumor surveillance based on pathology; photograph and assess recurrence / scar symptoms')] for i,(tm,bd) in enumerate(items): x=.65+i*2.48;y=1.65 if i%2==0 else 3.08 circ=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(x+.8),Inches(2.32),Inches(.55),Inches(.55));fill(circ,TEAL);line(circ,WHITE,1);text(s,x+.8,2.43,.55,.14,str(i+1),10,WHITE,True,PP_ALIGN.CENTER) rect(s,x,y,2.05,1.2,LIGHT,True,RGBColor(214,226,226));text(s,x+.14,y+.15,1.75,.22,tm,13,NAVY,True,PP_ALIGN.CENTER);text(s,x+.14,y+.46,1.75,.55,bd,10,GREY,False,PP_ALIGN.CENTER) rect(s,.72,5.5,11.9,.65,RGBColor(255,239,235),True,RGBColor(245,203,192));text(s,.95,5.69,11.45,.25,'Escalate urgently for expanding hematoma, rapidly worsening pain, flap pallor/coolness or venous congestion, progressive erythema, fever, purulent drainage, or wound separation.',13,RED,True) foot(s);add_notes(s,'There is no universal drain-output threshold or suture-removal day for all back wounds. State that local protocol and clinical examination should guide decisions. Pressure and shear avoidance are especially important on the back.') #9 complications s=prs.slides.add_slide(blank);title(s,'Complications: anticipate, recognize, respond','Trunk evidence reports mostly minor wound problems, but prevention matters',9) # statistic rect(s,.65,1.35,3.0,4.9,NAVY,True);text(s,.95,1.7,2.4,.35,'Trunk KDPIF review',16,AQUA,True,PP_ALIGN.CENTER);text(s,1.0,2.3,2.3,.8,'35.2%',40,WHITE,True,PP_ALIGN.CENTER);text(s,.95,3.2,2.4,.55,'overall reported\ncomplication rate',17,WHITE,True,PP_ALIGN.CENTER);text(s,.95,4.32,2.4,.85,'Infection 11.1%\nDehiscence 7.4%\nDelayed healing 7.4%\nPartial loss 1.9%',13,RGBColor(210,230,232),False,PP_ALIGN.CENTER) # grid probs=[('Hematoma / seroma','Meticulous hemostasis, drain when indicated','Evacuate if tense/expanding; culture if infection suspected'),('Dehiscence','Tension-free closure; activity restriction','Assess viability and depth; local care or delayed reclosure'),('Venous congestion / ischemia','No kinking, pressure or over-tight inset','Release constricting sutures/dressing; urgent senior review'),('Infection','Clean field; appropriate prophylaxis; dead-space control','Culture if purulent; antibiotics ± drainage/debridement')] for i,(a,b,c) in enumerate(probs): x=4.1+(i%2)*4.25;y=1.35+(i//2)*2.35;rect(s,x,y,3.88,1.92,PALE,True,RGBColor(210,224,224));text(s,x+.2,y+.18,3.4,.25,a,15,NAVY,True);text(s,x+.2,y+.58,3.35,.42,'Prevent: '+b,11,GREY);text(s,x+.2,y+1.18,3.35,.42,'Respond: '+c,11,RED) foot(s,'Source: systematic review of 54 trunk keystone flaps (2020).');add_notes(s,'Quote these as pooled descriptive review data, not a patient-specific prediction. The review had 54 flaps across eight studies; selection and reporting bias are likely. Use it to justify close wound surveillance.') #10 pearls s=prs.slides.add_slide(blank);title(s,'Technical pearls and avoidable pitfalls','A reproducible checklist for the operating room',10) left=[('Pearl','Mark after prone positioning and plan the resection and reconstruction together.'),('Pearl','Preserve a broad central perforator-bearing bridge: do not chase a single named perforator.'),('Pearl','Gain mobility by appropriate fascial release and V-Y closure, not by forceful traction.'),('Pitfall','Starting flap closure before the final oncologic defect and deep plane are known.'),('Pitfall','Ignoring back-specific pressure/shear after discharge.'),('Pitfall','Treating a threatened flap edge with observation alone when a constricting suture or hematoma is present.')] for i,(tag,body) in enumerate(left): y=1.33+i*.84;chip(s,.7,y,1.0,tag,GREEN if tag=='Pearl' else CORAL);text(s,1.95,y+.04,10.4,.42,body,15,NAVY if tag=='Pearl' else RED,tag=='Pearl') rect(s,.72,6.5,11.9,.42,RGBColor(234,247,244),True,RGBColor(191,225,211));text(s,.9,6.61,11.55,.18,'Take-home: Wide local excision determines cure; a well-planned keystone flap provides a fast, local, durable way to close selected posterior-trunk defects.',12,GREEN,True) foot(s);add_notes(s,'This slide is the practical ending. Emphasize that the right indication and tension management matter more than geometric adherence to a particular flap drawing.') #11 sources s=prs.slides.add_slide(blank);title(s,'Key references and discussion','Replace/add pathology-specific guidelines used by your multidisciplinary team',11) refs=[ '1. Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003.', '2. Song et al. A systematic review of the keystone design perforator island flap in reconstruction of trunk defects. Arch Plast Surg. 2020;47:??. PMCID: PMC7700866.', '3. The Keystone Perforator Island Flap: Review of Utility and Versatile Clinical Applications. 2024. PMCID: PMC10846774.', '4. Haddad et al. Keystone flap reconstruction after resection of a large paraspinal venous malformation in an infant. Plast Reconstr Surg Glob Open. 2020. PMID: 33173671.', '5. Mulholland and Greenfield’s Surgery, 7e. Wound healing: preoperative considerations include tissue perfusion, technique, nutrition and infection.', '6. Add your institutional pathway for antimicrobial prophylaxis, VTE prophylaxis, drain management, sarcoma/vascular tumor margin and surveillance protocols.' ] bullet(s,.8,1.45,11.8,4.65,refs,15,NAVY) rect(s,.8,6.2,11.7,.55,PALE,True,RGBColor(205,225,225));text(s,1.0,6.36,11.3,.22,'Thank you | Questions',18,TEAL,True,PP_ALIGN.CENTER) foot(s,'This educational deck is not a substitute for tumor-board or specialist reconstructive decision-making.');add_notes(s,'Invite discussion on the actual histology, desired margins, imaging and whether a unilateral or double keystone was chosen. Mention that pathology-specific guidelines should be added to the local final version.') # add slide number clickable? save prs.save(OUT) print(OUT) ''') PY python "/tmp/workspace/keystone-back-flap/src/create_deck.py" python - <<'PY' from pptx import Presentation p='/tmp/workspace/keystone-back-flap/output/Keystone_Flap_Back_Vascular_Tumor_Conference.pptx' prs=Presentation(p) print('slides',len(prs.slides)) for i,s in enumerate(prs.slides,1): text=' '.join(sh.text for sh in s.shapes if hasattr(sh,'text_frame')) print(i,len(text),text[:60]) PY

python - <<'PY' from pathlib import Path from pptx import Presentation p=Path('/tmp/workspace/keystone-back-flap/output/Keystone_Flap_Back_Vascular_Tumor_Conference.pptx') assert p.exists() and p.stat().st_size > 20000 prs=Presentation(str(p)) assert len(prs.slides)==11 assert all(any(getattr(sh,'has_text_frame',False) and sh.text_frame.text.strip() for sh in sl.shapes) for sl in prs.slides) print(f'validated: {p.name}, {p.stat().st_size} bytes, {len(prs.slides)} slides') PY

keystone perforator island flap posterior trunk surgical technique wide excision oncologic reconstruction review

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What was wrong with the first presentation? · What is the exact pathology to tailor margins and work-up?

keystone perforator island flap posterior trunk wide local excision reconstruction clinical technique review

~/keystone-back-flap/

keystone perforator island flap posterior trunk wide local excision figure flap markings closure

"keystone flap" AND trunk

https://pmc.ncbi.nlm.nih.gov/articles/PMC10846774/

python - <<'PY' from pathlib import Path p=Path('/tmp/workspace/keystone-back-flap/src/create_polished_deck.py') p.write_text(r'''from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.dml.color import RGBColor OUT='/tmp/workspace/keystone-back-flap/output/Polished_Keystone_Flap_Back_Vascular_Tumor_10min.pptx' prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5); blank=prs.slide_layouts[6] INK=RGBColor(18,35,52); INK2=RGBColor(47,65,80); TEAL=RGBColor(0,141,145); MINT=RGBColor(205,240,235); ICE=RGBColor(239,248,248); WHITE=RGBColor(255,255,255); ORANGE=RGBColor(243,125,74); YELLOW=RGBColor(244,185,69); RED=RGBColor(184,57,60); LINE=RGBColor(206,222,223); GREY=RGBColor(111,125,136); GREEN=RGBColor(44,139,100) def fs(s,c): s.fill.solid();s.fill.fore_color.rgb=c def ls(s,c=LINE,w=.8): s.line.color.rgb=c;s.line.width=Pt(w) def box(sl,x,y,w,h,c=WHITE,round=True,lc=LINE): s=sl.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if round else MSO_SHAPE.RECTANGLE,Inches(x),Inches(y),Inches(w),Inches(h));fs(s,c);ls(s,lc);return s def txt(sl,x,y,w,h,t,sz=16,c=INK,b=False,align=PP_ALIGN.LEFT,va=MSO_ANCHOR.TOP): tb=sl.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=Inches(.03);tf.margin_right=Inches(.03);tf.margin_top=Inches(.02);tf.margin_bottom=Inches(.02);tf.vertical_anchor=va for i,line in enumerate(t.split('\n')): p=tf.paragraphs[0] if i==0 else tf.add_paragraph();p.text=line;p.alignment=align;p.space_after=Pt(2) for r in p.runs:r.font.name='Aptos';r.font.size=Pt(sz);r.font.bold=b;r.font.color.rgb=c return tb def chip(sl,x,y,w,t,c=TEAL):box(sl,x,y,w,.32,c,True,c);txt(sl,x+.04,y+.055,w-.08,.18,t,9,WHITE,True,PP_ALIGN.CENTER) def bullet(sl,x,y,w,h,items,sz=15): tb=sl.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=Inches(.08);tf.margin_right=Inches(.03) for i,t in enumerate(items): p=tf.paragraphs[0] if i==0 else tf.add_paragraph();p.text=t;p.font.name='Aptos';p.font.size=Pt(sz);p.font.color.rgb=INK2;p.space_after=Pt(8);p.bullet=True return tb def title(sl,t,kicker,n): box(sl,0,0,13.333,.12,TEAL,False,TEAL);txt(sl,.58,.35,10.9,.18,kicker.upper(),9,TEAL,True);txt(sl,.58,.62,11.6,.48,t,27,INK,True);txt(sl,12.2,.46,.5,.2,f'{n:02}',10,TEAL,True,PP_ALIGN.RIGHT) def footer(sl): txt(sl,.58,7.18,11.5,.14,'Conference teaching deck | Tailor oncologic margins, adjuvant treatment and perioperative protocol to the case and MDT plan.',8,GREY);box(sl,.58,7.08,12.15,.01,LINE,False,LINE) def notes(sl,t):sl.notes_slide.notes_text_frame.text=t def arrow(sl,x1,y1,x2,y2,c=TEAL,w=2): l=sl.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2));ls(l,c,w) def circle(sl,x,y,d,c,lc=None): s=sl.shapes.add_shape(MSO_SHAPE.OVAL,Inches(x),Inches(y),Inches(d),Inches(d));fs(s,c);ls(s,lc or c);return s # 1 s=prs.slides.add_slide(blank);box(s,0,0,13.333,7.5,INK,False,INK);box(s,0,0,13.333,.13,TEAL,False,TEAL) txt(s,.72,.92,7.2,.22,'OPERATIVE STRATEGY',11,RGBColor(142,223,216),True) txt(s,.7,1.36,7.7,1.4,'Wide local excision\nwith keystone flap coverage',32,WHITE,True) txt(s,.74,3.03,6.7,.4,'Posterior trunk vascular tumor reconstruction',18,RGBColor(211,234,236)) # stylized posterior trunk / defect / flap box(s,9.0,.75,3.25,5.92,RGBColor(27,57,72),True,RGBColor(51,94,108));txt(s,9.3,1.12,2.65,.26,'POSTERIOR TRUNK',10,RGBColor(157,215,211),True,PP_ALIGN.CENTER) # center line a=s.shapes.add_shape(MSO_SHAPE.ARC, Inches(10.6), Inches(1.58), Inches(.25), Inches(4.4));a.fill.background();ls(a,RGBColor(91,142,151),1) e=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(10.12),Inches(3.15),Inches(1.12),Inches(1.35));fs(e,ORANGE);ls(e,WHITE,1.2);txt(s,10.22,3.66,.92,.18,'WLE\nDEFECT',10,WHITE,True,PP_ALIGN.CENTER) # keystone outline k=s.shapes.add_shape(MSO_SHAPE.PARALLELOGRAM, Inches(9.38), Inches(2.72), Inches(1.15), Inches(2.2));fs(k,RGBColor(64,153,151));ls(k,RGBColor(151,232,226),2) txt(s,.74,5.77,6.5,.23,'10-minute conference presentation',15,WHITE,True);txt(s,.74,6.21,6.8,.2,'Presenter | Unit | Meeting date',11,RGBColor(180,203,208)) notes(s,'Opening, 30 seconds. Present the reconstructive question: after adequate wide local excision on the back, how can we obtain reliable coverage without compromising oncologic clearance? The talk covers patient selection, marking, execution, and postoperative care. Replace the subtitle with your actual pathology before presenting.') # 2 s=prs.slides.add_slide(blank);title(s,'The reconstructive problem','WHY THIS CASE NEEDS A PLAN',2) txt(s,.63,1.34,4.65,.54,'Clear the tumor.\nClose the defect.\nProtect the result.',25,INK,True) box(s,.65,3.25,4.5,2.65,ICE,True,LINE);txt(s,.95,3.58,3.9,.25,'Posterior trunk challenges',16,TEAL,True);bullet(s,.93,4.08,3.85,1.45,['Defects expand after planned oncologic margins','High shear and pressure after prone / supine positioning','Dead space and tension can jeopardize healing'],14) # three pillars for i,(h,b,c) in enumerate([('ONCOLOGY','Histology, extent, margin and deep plane.',ORANGE),('MECHANICS','Laxity, tension vector and dead space.',TEAL),('BIOLOGY','Perfusion, smoking, nutrition, radiation.',GREEN)]): x=5.8+i*2.25; circle(s,x,1.66,.74,c);txt(s,x,1.89,.74,.15,str(i+1),13,WHITE,True,PP_ALIGN.CENTER);txt(s,x-.17,2.6,1.08,.24,h,11,INK,True,PP_ALIGN.CENTER);txt(s,x-.34,3.05,1.4,.85,b,12,INK2,False,PP_ALIGN.CENTER) arrow(s,6.52,2.03,7.93,2.03,LINE,2);arrow(s,8.77,2.03,10.18,2.03,LINE,2) box(s,5.72,4.7,6.65,.87,RGBColor(255,245,231),True,RGBColor(240,207,148));txt(s,5.98,4.97,6.12,.3,'The flap is selected only after the oncologic defect is understood.',16,RED,True,PP_ALIGN.CENTER) footer(s);notes(s,'About 45 seconds. State that the cancer treatment is pathology dependent. The flap is not a substitute for adequate margins. The key decision is whether adjacent back skin can be advanced without unacceptable tension or vascular risk.') #3 s=prs.slides.add_slide(blank);title(s,'Preoperative checklist','MAKE TWO PLANS BEFORE THE FIRST INCISION',3) cols=[('Tumor plan',['Confirm pathology and review imaging for depth and fascial or muscular involvement','Define margin and deep plane with the treating oncologic team','Record lesion size, location and photographs'],ORANGE),('Patient plan',['Assess scars, prior radiation, infection and local skin quality','Optimize smoking/nicotine exposure, glycemia, anemia and nutrition','Discuss bleeding, delayed healing, dehiscence and revision options'],TEAL),('Reconstruction plan',['Examine laxity in the planned prone position','Mark a unilateral flap and a rescue option: larger release, double keystone, regional/free flap','Plan drain and pressure-avoidance strategy'],GREEN)] for i,(h,arr,c) in enumerate(cols): x=.62+i*4.2;box(s,x,1.45,3.82,4.85,WHITE,True,LINE);chip(s,x+.28,1.77,1.63,h,c);bullet(s,x+.27,2.45,3.2,3.35,arr,14) footer(s);notes(s,'One minute. Show that preoperative planning is not only an anesthetic check. Skin and muscle blood flow, infection, nutritional status and operative technique influence wound healing. On the posterior trunk, inspect skin laxity after final positioning. Smoking and nicotine exposure impair wound healing and should be addressed before complex reconstruction where possible.') #4 s=prs.slides.add_slide(blank);title(s,'Why a keystone perforator island flap?','LOCAL TISSUE WITH MULTIPERFORATOR SUPPORT',4) # graphic box(s,.65,1.38,5.55,4.85,ICE,True,LINE);txt(s,.95,1.66,4.9,.23,'Conceptual movement',16,TEAL,True) # defect ellipse e=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(2.65),Inches(2.85),Inches(1.15),Inches(1.85));fs(e,RGBColor(255,229,220));ls(e,ORANGE,2);txt(s,2.8,3.57,.85,.2,'DEFECT',11,RED,True,PP_ALIGN.CENTER) # flap parallelogram f=s.shapes.add_shape(MSO_SHAPE.PARALLELOGRAM,Inches(4.2),Inches(2.48),Inches(1.22),Inches(2.58));fs(f,MINT);ls(f,TEAL,2);txt(s,4.39,3.55,.85,.2,'FLAP',11,TEAL,True,PP_ALIGN.CENTER) # perforators for yy in [3.1,3.8,4.5]:circle(s,4.63,yy,.13,ORANGE) arrow(s,5.4,3.28,3.92,3.28,TEAL,2.5);arrow(s,5.4,4.35,3.92,4.35,TEAL,2.5) txt(s,1.05,5.48,4.7,.24,'Two conjoined V-Y advancements release longitudinal tension.',13,INK2,False,PP_ALIGN.CENTER) # right list box(s,6.72,1.38,5.92,4.85,WHITE,True,LINE);txt(s,7.05,1.68,5.1,.25,'Strengths and limits',17,INK,True) for i,(h,b,c) in enumerate([('Strength','Like-with-like tissue, short arc of transfer, no separate donor-site defect',GREEN),('Useful for','Selected moderate trunk defects with adjacent supple skin and an intact vascular field',TEAL),('Escalate when','Irradiated/infected scar, exposed hardware, major volume loss or unclosable tension',ORANGE)]): y=2.27+i*1.12;chip(s,7.05,y,1.18,h,c);txt(s,8.4,y+.02,3.75,.48,b,13,INK2) footer(s);notes(s,'One minute. The keystone flap is a fasciocutaneous advancement flap supported by multiple perforators. It is often described as two conjoined V-Y flaps. It uses nearby skin with a good match and avoids a separate donor defect. Do not use it where the field is compromised or closure tension remains excessive after appropriate release.') #5 s=prs.slides.add_slide(blank);title(s,'Marking: geometry follows the defect','MARK AFTER POSITIONING, REASSESS AFTER EXCISION',5) box(s,.62,1.35,7.05,5.25,WHITE,True,LINE);txt(s,.92,1.64,6.4,.23,'Unilateral type IIa design - schematic',15,TEAL,True) # central defect / symmetrical labels e=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(3.38),Inches(2.6),Inches(1.2),Inches(2.45));fs(e,RGBColor(255,228,219));ls(e,ORANGE,2);txt(s,3.58,3.6,.8,.35,'final\ndefect',11,RED,True,PP_ALIGN.CENTER) f=s.shapes.add_shape(MSO_SHAPE.PARALLELOGRAM,Inches(5.08),Inches(2.18),Inches(1.75),Inches(3.25));fs(f,MINT);ls(f,TEAL,2.2);txt(s,5.52,3.62,.88,.22,'keystone\nflap',11,TEAL,True,PP_ALIGN.CENTER) # dimension lines arrow(s,3.32,2.42,4.63,2.42,ORANGE,1.3);txt(s,2.28,2.12,1.75,.2,'defect width',10,RED,True,PP_ALIGN.CENTER) arrow(s,5.05,5.74,6.86,5.74,TEAL,1.3);txt(s,4.92,5.92,2.12,.2,'flap width: starting guide',10,TEAL,True,PP_ALIGN.CENTER) # callouts for x,y,num,label in [(1.05,2.65,'1','Long axis parallel\nto defect'),(1.05,4.18,'2','Limb meets defect\nat ~90°'),(7.0,2.87,'3','Central bridge\nkeeps perforators'),(7.0,4.37,'4','Confirm mobility\nwith pinch test')]: circle(s,x,y,.32,TEAL);txt(s,x,y+.07,.32,.13,num,9,WHITE,True,PP_ALIGN.CENTER);txt(s,x+.42,y-.03,1.3,.5,label,10,INK2) box(s,8.13,1.35,4.5,5.25,ICE,True,LINE);txt(s,8.48,1.68,3.8,.23,'Marking rules',16,INK,True);bullet(s,8.43,2.22,3.65,3.4,['Mark lesion and intended margins before infiltration','Design in the most lax adjacent territory','Use Doppler selectively for large, scarred or irradiated fields','Have a second flap or alternate reconstruction drawn before incision'],14) footer(s);notes(s,'One minute. The traditional design places the long axis of the flap parallel to the elliptical defect and its curvilinear limbs meet the defect at about 90 degrees. A one-to-one defect to flap width is a common starting design in a recent clinical series, but this must be adjusted for skin laxity and defect depth. Mark a backup plan before committing.') #6 s=prs.slides.add_slide(blank);title(s,'Operative sequence','FOUR MOVES, ONE PRINCIPLE: MINIMIZE TENSION',6) steps=[('01','Resect','Complete the planned WLE to the intended deep plane. Orient and document the specimen.'),('02','Reassess','Measure the final defect. Confirm that the planned flap still matches the true defect and tension vector.'),('03','Release','Incise skin and subcutis. For a type IIa flap, release deep fascia along the outer curvilinear border as needed.'),('04','Advance & inset','Preserve the central perforator-bearing bridge. Advance gently, close V-Y ends, then inset in layers after hemostasis.')] for i,(n,h,b) in enumerate(steps): x=.64+(i%2)*6.13;y=1.38+(i//2)*2.42;box(s,x,y,5.75,1.88,WHITE,True,LINE);circle(s,x+.28,y+.28,.52,TEAL);txt(s,x+.28,y+.45,.52,.12,n,9,WHITE,True,PP_ALIGN.CENTER);txt(s,x+1.0,y+.27,4.2,.22,h,17,INK,True);txt(s,x+1.0,y+.68,4.35,.74,b,13,INK2) box(s,.7,6.23,11.93,.48,RGBColor(255,244,230),True,RGBColor(239,206,144));txt(s,.98,6.36,11.36,.18,'Do not skeletonize a single perforator or force a blanched edge into closure. Re-plan rather than over-tension the inset.',12,RED,True,PP_ALIGN.CENTER) footer(s);notes(s,'One minute 15 seconds. The key operative teaching point is that the flap is multiperforator based. It should not be treated as a flap on one dissected pedicle. Raise it with sufficient release to advance comfortably while preserving the central vascular bridge. Re-check capillary refill and edge color before dressing.') #7 s=prs.slides.add_slide(blank);title(s,'Inset and immediate postoperative plan','CONTROL DEAD SPACE. PROTECT FROM SHEAR.',7) for i,(h,arr,c) in enumerate([('Hemostasis & dead space',['Meticulous hemostasis before final closure','Consider quilting/progressive-tension sutures when appropriate','Use a closed suction drain if a meaningful cavity remains'],ORANGE),('Layered closure',['Close V-Y ends to recruit laxity','Use deep dermal support, then skin closure without strangulation','Consider reinforced mattress sutures at the highest-tension leading edge'],TEAL),('Dressing & position',['Non-compressive dressing or incisional negative-pressure dressing per local practice','Avoid direct pressure and friction over the flap','Give clear activity and lifting restrictions'],GREEN)]): x=.65+i*4.2;box(s,x,1.58,3.8,4.75,WHITE,True,LINE);chip(s,x+.28,1.9,2.2,h,c);bullet(s,x+.3,2.57,3.1,2.9,arr,14) footer(s);notes(s,'About 50 seconds. Posterior trunk defects often have a cavity and are exposed to movement and pressure. Choose drain use based on dead space and hemostasis, rather than applying a universal rule. A published upper-back case series used 1 to 2 drains and incisional negative-pressure dressings, but your local practice may differ.') #8 s=prs.slides.add_slide(blank);title(s,'Postoperative surveillance','THE FIRST WOUND REVIEW IS A FLAP ASSESSMENT',8) # timeline arrow(s,1.1,3.18,12.2,3.18,LINE,3) items=[('0-24 h','Color, warmth, capillary refill, hematoma and dressing pressure'),('POD 1-3','Pain, drain output, seroma, infection, activity and pressure avoidance'),('Week 1-2','Wound review, drain decision, suture plan and pathology / MDT review'),('Weeks 2-6','Limit shear/lifting; review healing, scar and adjuvant-treatment timing')] for i,(h,b) in enumerate(items): x=.73+i*3.08;circle(s,x+1.03,2.81,.72,TEAL);txt(s,x+1.03,3.06,.72,.15,str(i+1),11,WHITE,True,PP_ALIGN.CENTER);box(s,x,1.37,2.78,1.12,ICE,True,LINE);txt(s,x+.18,1.62,2.42,.19,h,13,INK,True,PP_ALIGN.CENTER);box(s,x,4.05,2.78,1.38,WHITE,True,LINE);txt(s,x+.18,4.28,2.42,.78,b,12,INK2,False,PP_ALIGN.CENTER) box(s,.74,5.96,11.85,.6,RGBColor(255,234,232),True,RGBColor(244,193,189));txt(s,.98,6.14,11.35,.2,'Act early for expanding hematoma, increasing pain, pallor/coolness, venous congestion, purulent drainage, fever, or progressive wound separation.',13,RED,True,PP_ALIGN.CENTER) footer(s);notes(s,'One minute. Surveillance is primarily clinical. Assess flap color, warmth and capillary refill, and look for a compressive hematoma or dressing. Back-specific aftercare includes avoiding direct pressure and shear. In a reported upper-back KPIF series, a small dehiscence occurred after repeated heavy lifting around postoperative day 21, so activity restrictions should be explicit.') #9 s=prs.slides.add_slide(blank);title(s,'Complications: prevention and response','KNOW THE FAILURE MODES BEFORE THEY HAPPEN',9) box(s,.65,1.36,3.05,4.9,INK,True,INK);txt(s,.94,1.72,2.45,.2,'TRUNK KDPIF REVIEW',11,RGBColor(150,222,217),True,PP_ALIGN.CENTER);txt(s,.98,2.18,2.35,.7,'35.2%',39,WHITE,True,PP_ALIGN.CENTER);txt(s,.95,3.05,2.45,.5,'reported overall\ncomplication rate',15,WHITE,True,PP_ALIGN.CENTER);txt(s,.97,4.1,2.37,.9,'Infection 11.1%\nDehiscence 7.4%\nDelayed healing 7.4%\nPartial flap loss 1.9%',13,RGBColor(207,230,231),False,PP_ALIGN.CENTER) for i,(h,p,r) in enumerate([('Hematoma / seroma','Hemostasis, dead-space control','Evacuate if tense or expanding'),('Dehiscence','Low-tension inset, limit shear','Assess depth/viability; local care or reclosure'),('Threatened perfusion','No compression or kinking','Release constriction; urgent review'),('Infection','Clean field, drain when needed','Culture, antibiotics, drain/debride as indicated')]): x=4.1+(i%2)*4.28;y=1.36+(i//2)*2.38;box(s,x,y,3.9,1.92,WHITE,True,LINE);txt(s,x+.23,y+.2,3.25,.2,h,15,INK,True);txt(s,x+.23,y+.59,3.3,.3,'Prevent: '+p,11,INK2);txt(s,x+.23,y+1.18,3.3,.3,'Respond: '+r,11,RED) footer(s);notes(s,'One minute. Quote the evidence cautiously: the systematic review included only 54 trunk flaps from eight case series, with heterogeneous techniques and patient selection. It is useful for anticipating wound problems, but not for predicting an individual patient’s risk. The main message is early recognition of hematoma, wound tension and perfusion compromise.') #10 s=prs.slides.add_slide(blank);title(s,'Take-home algorithm','A REPRODUCIBLE APPROACH TO SELECTED BACK DEFECTS',10) # algorithm labels=[('1','Define oncologic resection','Pathology, imaging, margins, deep plane'),('2','Assess final defect','Size, depth, adjacent skin, tension'),('3','Select reconstruction','Single KPIF if local tissue is healthy and advances comfortably'),('4','Execute safely','Preserve perforator bridge, release appropriately, close without tension'),('5','Protect outcome','Dead-space control, pressure/shear avoidance, structured follow-up')] for i,(n,h,b) in enumerate(labels): y=1.42+i*1.0;circle(s,.82,y,.48,TEAL if i<4 else GREEN);txt(s,.82,y+.15,.48,.12,n,9,WHITE,True,PP_ALIGN.CENTER);txt(s,1.53,y+.03,3.35,.2,h,15,INK,True);txt(s,5.2,y+.04,6.75,.35,b,13,INK2);arrow(s,1.06,y+.5,1.06,y+.95,LINE,1.5) box(s,.72,6.55,11.85,.38,RGBColor(230,247,241),True,RGBColor(183,224,207));txt(s,.93,6.65,11.45,.15,'Wide local excision determines oncologic adequacy. A well-planned keystone flap can provide efficient, durable local coverage for selected posterior-trunk defects.',12,GREEN,True,PP_ALIGN.CENTER) footer(s);notes(s,'Closing, 30 seconds. End with the algorithm: first plan the cancer, then inspect the real defect, then select the simplest reconstruction that closes without compromising perfusion or tension. A keystone flap is a reliable local option for selected cases, not an automatic choice for every back defect.') #11 refs s=prs.slides.add_slide(blank);title(s,'References','EVIDENCE BASE AND CASE-SPECIFIC ADDITIONS',11) refs=['Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003.','Rini IS, Gunardi AJ, Marsaulina RP, et al. A systematic review of the keystone design perforator island flap in the reconstruction of trunk defects. Arch Plast Surg. 2020;47:535-541. PMCID: PMC7700866.','The Keystone Perforator Island Flap: Review of Utility and Versatile Clinical Applications. 2024. PMCID: PMC10846774.','Mulholland and Greenfield’s Surgery, 7e. Clinical assessment: tissue perfusion, surgical technique, nutrition and infection influence wound healing.','Add pathology-specific guideline(s), imaging, MDT recommendation and institutional antibiotic/VTE/drain protocol before presentation.'] box(s,.7,1.35,11.9,4.85,WHITE,True,LINE);bullet(s,.98,1.72,11.25,3.85,refs,15) box(s,.7,6.38,11.9,.4,ICE,True,LINE);txt(s,.95,6.49,11.4,.17,'Thank you | Questions',17,TEAL,True,PP_ALIGN.CENTER) footer(s);notes(s,'Use this slide only if time permits or as backup. Before presenting, add the exact pathology guideline and your patient’s imaging and histology. Do not present generic margin recommendations for an unspecified vascular tumor.') prs.save(OUT);print(OUT) ''') PY python "/tmp/workspace/keystone-back-flap/src/create_polished_deck.py" python - <<'PY' from pptx import Presentation p='/tmp/workspace/keystone-back-flap/output/Polished_Keystone_Flap_Back_Vascular_Tumor_10min.pptx' prs=Presentation(p) print('slides:',len(prs.slides),'notes:',sum(bool(s.notes_slide.notes_text_frame.text.strip()) for s in prs.slides)) print('bytes:',__import__('os').path.getsize(p)) PY

~/keystone-back-flap/output/