Advancement Flap Research Articles

Tunnel vs. coronally advanced flap in combination with a connective tissue graft for the treatment of multiple gingival recessions: a multi-center randomized clinical trial

ObjectiveTo evaluate the efficacy of the partial-thickness non-advanced tunnel technique (TUN) versus the coronally advanced flap (CAF), both combined with a connective tissue graft, in the treatment of multiple gingival recessions.Materials and methodsTwenty-nine patients (83 teeth) affected by multiple gingival recessions were treated in two clinical centers with either the test (TUN) or the control (CAF) intervention combined with a connective tissue graft. Outcomes at 3 and 6 months after surgery included complete root coverage (CRC—primary outcome), mean root coverage (mRC), changes in recession depth (RD), probing pocket depth (PPD), and keratinized tissue height (KT). Root sensitivity and root coverage esthetic score (RES) were also evaluated at 6-month examination. Surgery duration, wound healing index (WHI), and patient-reported outcome measures (PROMs) were additionally considered.ResultsAt 6 months, CRC was observed in 80.9% and 79.5% of the teeth treated with TUN and CAF, respectively (odds ratio = 1.2; p = 0.802). No differences between groups were also observed in terms of mRC (TUN = 94.0%; CAF = 91.1%), RD and PPD reductions, root sensitivity, RES, and WHI. KT increase was significantly higher in teeth treated with TUN (Difference in Means – MD = − 1.0 mm; p = 0.001). Surgery duration was shorter (MD = − 19.3 min; p = 0.001), and patients reported less intra-surgical pain (MD = − 16.4; p = 0.028) as well as postoperative morbidity in TUN compared with CAF.ConclusionsBoth surgical interventions showed a similar efficacy in terms of root coverage, albeit TUN was associated with a higher increase in KT and with a milder patient’s surgical experience.Clinical relevanceBoth techniques have shown similar efficacy for the coverage of exposed root surfaces, although clinicians may consider TUN as less invasive.Trial registrationClinicaltrials.gov (NCT05122468)

Fissurectomy with mucosal advancement flap anoplasty: The end of a dogma?

The goal was to compare fissurectomy with mucosal advancement flap anoplasty to fissurectomy alone in the surgical treatment of anal fissure. This study included patients who underwent surgery in 2019 for solitary, idiopathic, non-infected, posterior anal fissure, after failure of medical treatment. The choice to perform advancement flap anoplasty was based on surgeon preference and did not depend on the fissure itself. The main endpoint was the time to relief of pain. Of 599 fissurectomies performed during the study period, 226 patients (37.6% women, mean age 41.7±12.0 years old) underwent fissurectomy alone (n=182) or associated with advancement flap anoplasty (n=44). The two groups differed as to their sex ratio (33.5 vs. 54.5% women, P=0.01), body mass index (25.3±4.0 vs. 23.6±3.9, P=0.013) and Bristol score (3.2 vs. 3.4, P=0.038). Time to relief of pain, time to disappearance of bleeding and time to healing were 1.1 (0.5-2.3), 1.0 (0.5-2.1) and 2.0 (1.1-3.6) months, respectively. The rate of healing was 93.8% and the complication rate was 6.2%. The differences between the two groups for these outcomes were not statistically significant. The risk factors associated with absence of healing were age≥40 years (Odds ratio (OR): 3.84; 95% CI, 1.12-17.68) and pre-surgical duration of fissure<35.6 weeks (OR: 6.54; 95% CI: 1.69-43.21). Mucosal advancement flap anoplasty does not provide any added value to fissurectomy alone.

An Optimizing Surgical Procedures for Correcting Severe Constricted Ears: Helix Costal Cartilage Scaffold Combined With V-Y Advanced Flap.

A constricted ear is a deformity that is distinguished by curling of the upper portion of the ear, which includes the helix, scapha, and antihelix. The treatment for severely constricted ears seems to be quite invasive. To reduce invasiveness and fully utilize the folded cartilage, the authors used a helix costal cartilage scaffold combined with a single V-Y advanced flap in the correction of Tanzer type IIB constricted ear deformity to investigate the clinical effect. From 2020 to 2021, autologous costal cartilage helix stent combined with local V-Y advanced flap was applied to correct the constricted ear malformation in 18 patients admitted to the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences. All patients were followed for a duration of 6 to 12 months (average 7 months). Reconstructed auricles were cosmetically satisfying, with a natural-looking helix and enlarged cavum conchae cavity, as well as auricle sizes that were close to normal and near symmetry between both ears. With satisfactory clinical results, our technique can be used to repair types IIB cup ear deformities. It has a broad range of practical applications.

Effektivität von Mukosa Muskel Flaps in der Behandlung von perianalen Fisteln bei Morbus Crohn und kryptoglandulären Fisteln – eine Langzeit-Follow-up-Studie

Surgical treatment of perianal fistulae originating from Crohn's Disease (CD) or cryptoglandular abscess (CGA) remains a challenge. Data on long-term healing rates are scarce. We aimed to evaluate the long-term success rate of mucosal advancement flap (MAF) operations. This single centre retrospective analysis was performed at a tertiary referral centre (Charité University Hospital Berlin, Campus Benjamin Franklin) between March 1, 2010 and March 31, 2020. Patients with complex perianal fistulae originating from CD or CGA treated with MAF were included. Long-time healing rates of MAF in CGA and CD were compared. Regression analysis was used to identify predictive factors for definitive healing. 83 patients (24 CD, 59 CGA,) were included. Median follow-up for CD was 5.4 and 1.9 years for CGA. Definitive healing of fistulae was achieved in 19 (79.2%) CD patients (p=0.682) and in 44 (74.6%) CGA patients. Healing time was significantly shorter in CGA than in CD (9.3 months [standard deviation: SD=11.3 months] vs. 30.9 months [SD=23.5 months]; p<0.001). Treatment with biologicals (hazard ratio: HR=0.18, 95%-confidence interval: 95%-CI=0.06-0.59, p=0.004) and diverting ileostomy (HR=0.29, 95%-CI=0.10-0.85, p=0.023) in CD were independent predictors for MAF success. Simultaneous medication with azathioprine in CD was an independent predictor for MAF failure (HR=3.20, 95%-CI=1.05-9.81, p=0.041). This study demonstrates that surgical therapy of perianal fistulae with MAF is successful in about 75% of patients overall. Patients with MC benefit from biologicals and a diverting ileostomy. Treatment with azathioprine had a negative impact on recurrence rates. Repeated MAF operations did not increase the risk of failure in subsequent operations.

Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes.

Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.

Giant basal cell carcinoma of the scalp: rotation advancement flap as a successful dermatosurgical approach.

Giant keratinocyte tumors, in particular basal cell carcinomas of the scalp area, are a serious challenge for dermatosurgeons, oncologists, and maxillofacial and reconstructive surgeons. The scalp area is limited in terms of skin mobility, and its elasticity decreases with age. The size of the tumors in this area and the degree of infiltration of the underlying tissues are important for the therapeutic choice, from surgical removal, waiting for granulations to form, and placing a split skin mesh graft (at a later stage) to performing complex rotational/transpositional or advancement flaps. Achieving an optimal aesthetic result is often the consequence of interventions carried out or based on the decisions of multidisciplinary teams. Alternatives, such as radiotherapy and targeted therapy with vismodegib, could be administered both preoperatively and postoperatively or as first-line therapy, depending on the tumor board decisions. We present the case of a 69-year-old female patient with a histopathologically proven preoperative giant basal cell carcinoma of the scalp that did not infiltrate the tabula externa. A preoperative ultrasound was performed to preserve the feeding flap arteries. Surgical treatment under general anesthesia was planned and subsequently carried out. During surgery, the surgical resection lines were in close proximity to the arterial vessels, but they remained preserved and ensured a subsequently unproblematic healing process. After the application of the rotational advancement flap technique under general anesthesia, an optimal cosmetic effect was achieved.

Combined Tripier and V-Y Advancement Flaps for Reconstruction of Large Lid-cheek Junction Defects

Reconstruction of lid-cheek junction defects has a known risk of ectropion. Cervicofacial flaps require significant dissection and can still be prone to ectropion. V-Y advancement flaps have been described as less morbid, but their use is limited to moderate-size defects that do not involve the lid margin. The authors present a technique of combined Tripier and V-Y advancement flaps for reconstruction of large defects of the lid-cheek junction involving the lower eyelid. A retrospective review of patients undergoing the authors' technique was performed. A facial artery perforator flap was designed in a V-Y fashion and advanced into the cheek. An orbicularis oculi myocutaneous flap (Tripier flap) was elevated from the upper eyelid and rotated into the lower eyelid/upper cheek to meet the superior edge of the V-Y flap. A separate review of patients undergoing cervicofacial flap reconstruction was also performed. Demographics, operative details, and complications were recorded and compared. This technique was applied to five patients with large-size (19.9 ± 5.6 cm2) defects of the lid-cheek. In all cases, healing was achieved without ectropion, hematoma, infection, dehiscence, flap necrosis, or facial nerve injury. Twenty-four patients separately underwent cervicofacial flap reconstruction for defects of comparable size (15.8 ± 10.7 cm2). Two patients developed ectropion, one patient developed a hematoma, and two patients developed an infection. Combined Tripier and V-Y advancement flaps is a useful technique to reconstruct lid-cheek junction defects. This method allows for the reconstruction of large lid-cheek junction defects that involve the lid margin.

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes.

Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure. To assess the incidence of PRF and to report on the outcomes of available surgical treatments. A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020. 34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +). PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Comparison of chorion allograft and subepithelial connective tissue autograft in the treatment of gingival recession- A randomized controlled clinical trial.

To compare the clinical outcomes of subepithelial connective tissue graft and chorion membrane along with coronally advanced flap in the treatment of gingival recession. A total of 12 patients with 24 sites showing isolated bilateral Miller's class I and II gingival recessions were randomly allocated into two treatment sites. One site, connective tissue graft, (n=12 sites) while on the contra-lateral site, chorion membrane (n=12 sites) was used with coronally advanced flap. Clinical parameters: probing depth, recession depth, recession width, width of keratinized gingiva, relative attachment level, thickness of keratinized gingiva were recorded at the baseline, 3 months, and 6 months. The amount of root coverage was evaluated after 6 months. Statistically significant differences were observed between test and control sites in terms of recession depth, recession width, width of keratinized gingiva and thickness of keratinized gingiva at 6 months. The test sites presented 66.17±18.85% and the control site showed 87.17±18.33% of root coverage at 6 months. Very limited amount of recession coverage with chorion membrane and did not serve as an alternative to connective tissue graft. CTRI/2017/12/010964.

Coronally Advanced Flap with Xenogeneic Collagen Matrix for the Treatment of Gingival Recessions at Sites Presenting with Cervical Restorations or Noncarious Cervical Lesions: A Clinical and Ultrasonographic Study.

The aim of this prospective study was to evaluate the efficacy of a cross-linked xenogeneic volume-stable collagen matrix (CCM) in treating gingival recessions (GRs) at teeth presenting with cervical restorations or noncarious cervical lesions (NCCLs). Fifteen patients with esthetic concerns for multiple sites with GRs and cervical restorations were consecutively enrolled. The sites were treated with a coronally advanced flap (CAF) design in combination with a CCM. When present, the previous restoration was removed, and the cementoenamel junction was reconstructed with a composite material. The CCM was stabilized on the root surface(s) previously occupied by the restoration. The CAF was sutured to completely cover the graft. Clinical measurements and intraoral digital and ultrasonographic scans were collected at baseline and at 3 and 6 months postsurgery. Limited postoperative discomfort was reported by patients during the healing. The mean root coverage at 6 months was 74.81%. Average increases in gingival thickness of 0.43 mm and 0.52 mm were observed when measured with ultrasonography 1.5 mm and 3 mm apical to the gingival margin, respectively (P < .05). Relatively high patient-reported satisfaction and esthetics were associated with the treatment outcomes. The treatment resulted in a significant reduction in dental hypersensitivity (mean: 33 VAS points). The present study demonstrated that CAF + CCM is an effective approach for treating GRs at sites with cervical restorations or NCCLs. Int J Periodontics Restorative Dent 2023;43:147-154. doi: 10.11607/prd.6448.

Efficacy of a fingertip reconstruction technique using the tongue-shaped flap and advancement flap for repairing congenital syndactyly with osseous fusion of the distal phalanges

BackgroundTo explore the clinical efficacy of using tongue-shaped flaps and advancement flaps to reconstruct the fingertips in congenital syndactyly patients with osseous fusion of the distal phalanges. MethodsFrom January 2016 to January 2019, 12 patients with congenital syndactyly, involving 30 digits in total, presented to our hospital and were surgically treated with tongue-shaped flaps, as well as with advancement flaps to reconstruct the fingertips. The flap infection rate, necrosis rate and any other early complications were recorded. Fingertip aesthetics were reported according to the modified Bulic scale. A questionnaire was used to assess the satisfaction of the patients’ family members. ResultsAll cases were thoroughly reviewed. The postoperative period for inclusion in this study ranged from 36 to 60 months, with an average follow-up time of 45 months. During this period, no complications such as infection and/or necrosis of any flap were observed. Significant improvements in finger aesthetics and functioning compared to preoperative values were observed in most cases. Based on the modified Bulic scale, of 30 fingertips, an excellent result was obtained for 3, a very good result for 13, a good result for 13 and a poor result for just 1. Family members were satisfied with the treatment outcome. ConclusionsThis technique employing tongue-shaped flaps and advancement flaps to reconstruct fingertips is effective, which enables the attainment of favourable aesthetic and functional outcomes in congenital syndactyly patients with osseous fusion of the distal phalanges.

Marjolin’s Ulcer of the Scalp: A Case Operated with Reconstruction by Advancement Flap Completed by a Skin Graft Performed at the Sominé Dolo Hospital in Mopti (Mali)

Introduction: Cutaneous squamous cell carcinoma encompasses about 16% of scalp tumors. They can arise de novo or more often mark the evolution of lesions considered as non-invasive precursors: actinic keratoses and Bowen's disease more rarely, they occur on a burn scar (Marjolin's ulcer). We report a case of invasive squamous cell carcinoma on a burn scar (Marjolin's Ulcer) operated with reconstruction by advancement flap completed by a skin graft performed at the Sominé Dolo hospital in Mopti (Mali). A 62-year-old Malian man consulted for a scalp ulceration that had been evolving for 10 years. The lesion began with small trailing erosion that appeared on a burn scar. There was no notion of initial trauma and the patient had no particular history. Physical examination found a large ulceration (6×4 cm) of parietal seat on the scalp with a fibrinous bottom and a sclerotic border. There was a large left latero -cervical mass measuring 13 x 6 cm. The computed tomography of the skull did not find any bone lesions and that of the latero -cervical mass was in favor of adenopathy. Histological examination of a biopsy fragment confirmed the diagnosis of invasive squamous cell carcinoma. Deep resection removing the tumor with the periosteum exposing the parietal bone was performed. Reconstruction by advancement-rotation flap supplemented by a skin graft was performed. The management of squamous cell carcinoma is based on surgery, which is the reference treatment, against which other treatments must be compared. On the scalp, Rotation-advancement flaps are the preferred one-stage surgical repair technique.

A COMPARATIVE EVALUATION OF VESTIBULAR INCISION SUBPERIOSTEAL TUNNEL ACCESS (VISTA) VERSUS CORONALLY ADVANCED FLAP WITH COLLAGEN MEMBRANE FOR THE TREATMENT OF MILLERS CLASS I AND CLASS II GINGIVAL RECESSION: A CLINICAL STUDY

Background: Gingival recession is defined asThe displacement of soft tissue margin apical to CEJ with exposure of root surface. Factors such as abnormal tooth alignment in the arch, fenestration, dehiscence, faulty tooth brushing, periodontal diseases etc. are few of the causes of gingival recession. The aim of the present study was to compare the effectiveness of minimally invasive Vestibular Incision Subperiosteal Tunnel Access (VISTA) technique and coronally advanced flap using a bioresorbable collagen membrane in Millers Class I and II gingival recessions Material and Methods: 20 sites with Millers Class I or II gingival recession were recruited and allocated into 2 groups with 10 sites each. Test group: VISTA with bioresorbable collagen membrane control group: CAF with bioresorbable collagen membrane. Plaque Index (PI), Gingival Index (GI), relative Clinical attachment level (CAL) Pocket Probing Depth (PPD) Recession Height (RH) and width of keratinized gingiva (WKG) Recession Width (RW) were measured at baseline 3 months and 6 months. Results: A significant improvement was found in all the clinical parameters in the Test group from baseline to 3 months and 6 months Recession width reduction was significantly more in the Test group as compared to Control group. Conclusion: Both the groups, viz: VISTA with resorbable collagen membrane and CAF with resorbable collagen membrane were effective in the treatment of Millers Class I and II gingival recessions VISTA being minimally invasive can be used for covering recession defects.

The Significance of Mylohyoid Muscle Release (MMR) in the Vertical and Horizontal Ridge Augmentation Surgeries; Clinical and Human Cadaver Analyses of the Techniques

(1) Background: Ridge augmentations either horizontal (HRA) or vertical (VRA) in the posterior mandible are very challenging regenerative procedures. To attain and retain tension-free primary closure, buccal periosteal and mylohyoid muscle releases should be performed. The purpose of the present study was to review, analyze and discuss the three different techniques for the mylohyoid muscle release (MMR) in VRA and HRA surgeries on a clinical and human cadaver level. (2) Presentation of the techniques: Three different techniques are described in the literature regarding the lingual flap management: (i) the finger sweep technique (FST), (ii) the release of the mylohyoid muscle attachment on the lingual flap (MMALF), and (iii) the mylohyoid preservation technique (MPT) in three key anatomical zones. All three techniques, even though they use a different approach, can achieve similar amount of horizontal and vertical mylohyoid muscle release although MPT showed statistically significant higher flap advancement. The human cadaver analyses revealed that all three techniques are considered safe since they do not approximate vital anatomical structures. (3) Conclusions: All three techniques are considered safe, but they are not free of limitations or complications; therefore, they should be performed only by highly experienced and trained clinicians. MPT achieved statistically significant higher flap advancement.

Rare presentation of penile cancer: a case report

Penile cancer is rare. Squamous cell cancer usually starts on glans or coronal sulcus as a nodule, foul smelly ulcer or cauliflower like mass, which invades corpora cavernosa as it progresses sparing the urethra until late in the course of the disease.We report a case of 32-year-old male with squamous cell carcinoma of penis in the form of ulcer involving shaft of penis at the base with surrounding inguinoscrotal region managed with en-mass wide local excision of the malignant ulcer taking 1 cm margin from all sides with total penectomy with partial left scrotal skin excision with left orchidectomy with perineal urethrostomy with local scrotal advancement flap reconstruction with bilateral superficial inguinal lymphnode biopsy. Post op period was satisfactory. At discharge, flap was healthy with well-functioning perineal urethrostomy. Patienthad received 6 cycles of adjuvant chemotherapy.Ca penis can be present in any rare form and hence early diagnosis and timely management is the key.

Effectiveness of Plasma-Rich Fibrin and De-Epithelialized Free Gingival Graft in the Treatment of Gingival Recessions

Introduction/Aim: Soft tissue dehiscences such as gingival recessions are a very common problem that we face in modern periodontics. This clinical study aimed to analyze the effectiveness of surgical procedures using a de-epithelialized gingival graft (DGG) combined with a coronally advanced flap and to evaluate the application of plasma-rich fibrin (PRF). Methods: The study included 40 teeth (20 patients) with Miller class I and II gingival recessions. Twenty recessions (20 patients) were treated utilizing the de-epithelialized gingival graft in combination with the coronally advanced flap, and on the opposite side of the jaw, the same number of recessions were treated utilizing plasma-rich fibrin combined with the coronally advanced flap. To evaluate tissue condition and the clinical parameters before and after the surgical procedure, the following parameters were used: the degree of epithelial attachment (DEA), the width of keratinized gingiva (WKG), and the vertical depth of recession (VDR). Results: based on the achieved results and the analysis of clinical parameters, a statistically significant reduction in the vertical depth of recession was proven in both groups, with very similar mean percentages of root coverage, with the difference being that the stability of the soft tissues of the treated region was more visible in the DGG. Conclusion: using modern surgical procedures allows the regeneration of not only the soft tissues but also deeper periodontal tissues.

The 1-2-3 cm Advancement Flap Rule in Scalp Reconstruction.

Background Defects of the scalp are surgically challenging for several reasons: anatomical convexity limits tissue displacement, resistance to advancement is different at different points on the scalp, and there is also interindividual variation. For many patients, the idea of undergoing an advanced surgery such as a free flap is not preferred. Hence, a simple technique with a favorable outcome is needed. We hereby introduce our new technique: the 1-2-3 scalp advancement rule. Objectives The objective of this study is to discover a novel way to reconstruct scalp defects secondary to trauma or cancer, without having the patient undergo a big procedure. Material and Methods A total of nine cadaveric heads were used to testthe idea of achieving greater advancement and increased scalp mobility to cover a 4×8 cm-sized defect using our proposed 1-2-3 scalp rule. Three steps performed wereadvancement flap, galeal scoring, and removal of the outer table of the skull. The measurement of advancement was recorded after each step, and the results were analyzed. Results The mobility of the scalp was calculated from the sagittal midline with identical arcs of rotation. With zero tension, we found that the total distance ofadvancement with a flap had a mean of 9.78 mm, while the advancement for the same flap after galeal scoring had a mean of 20.5 mm, and after removing the outer table, the mean advancement was 30.2 mm. Conclusion To create a tension-free closure necessary for optimal outcome for scalp defects, our study showed that increased distances were possible using galeal scoring and outer table removal, increasing the distance of advancement by 10.63 mm and 20.42 mm, respectively.

Making Headway in Surgical Education at Home and Abroad: Use of an Inexpensive Three-Dimensional Learning Model to Improve Plastic Surgery Resident Confidence in Mohs Defect Assessment and Closure Planning.

The development of simulation, particularly low-cost models, has become a focus of interest within plastic surgery education. Current simulators for Mohs reconstruction are either expensive or not reusable. The authors hypothesize that using a Styrofoam head model during an interactive teaching session will positively affect plastic surgery trainee comfort in designing Mohs reconstructive options. A cohort of integrated plastic surgery residents at a single institution performed a preactivity questionnaire to obtain baseline comfort in defect assessment and design for five Mohs defects. They subsequently underwent an interactive learning session and were instructed to design flaps on life-size Styrofoam heads with feedback from the senior author (M.L.B.). A postactivity questionnaire was completed to assess improvement in comfort in defect assessment and flap design. Three attending surgeons then compared trainee designs with the senior author's design to assess accuracy. All surveys were based on a five-point Likert scale. When analyzing all defects, average postactivity scores increased by 0.63 (SD, ±0.24) ( P = 0.008). Junior residents ( n = 8) had a greater increase in average score responses [mean, 1.07 (0.5 to 1.75)] compared with senior residents ( n = 9) [mean, 0.27 (0 to 1)] ( P < 0.001). When assessed by senior-level surgeons, senior residents had significantly greater accuracy in design for each defect ( P < 0.05) except cheek advancement flap ( P = 0.08). Participation in an interactive educational activity using a Styrofoam head model demonstrated significant improvements in trainee assessment and design of reconstructive options for Mohs defects.

A case of oroantral fistula: managed successfully by buccal advancement flap

Oral epithelium migrates into the defect when an oroantral communication lasts more than three weeks, at which point it is referred to as an oroantral fistula. Oroantral fistula (OAF) can arise for a variety of reasons, including the extraction of maxillary posterior teeth, treatments for sinus augmentation, the improper use of implant drills, trauma to the craniofacial region, osteoradionecrosis, and flap necrosis. The size of the pre-existing oroantral communication affects the oroantral fistula’s treatment strategy and outcome. Instances when the oroantral communication is lesser than 2 mm in diameter it’s likely to heal and close by itself, eliminating the need for any surgical intervention. However, surgical closure is advised when the oroantral communication is higher than 3 mm or linked to periodontal or maxillary infection. In the literature, a number of algorithms have been proposed to describe the surgical methods for treating oroantral fistulas. This article aims to discuss a case of oroantral fistula of a female patient aged 34 years who presented with the chief complaint of foul discharge from the nose since 2 months.

Soft Tissue Reconstruction of the Posterior Trunk after Tumor Excision: A Surgical Algorithm

The posterior trunk has been considered a challenging area to reconstruct following soft tissue tumor excision because of the shortage of local donor sites. The advent of innovative procedures such as perforator flaps has radically changed this perspective and offered a new approach to the problem. Upon a review of the literature and the personal experiences of the senior author, an algorithm is developed according to the most updated procedure, combined with more conventional options that maintain a role in decision-making. The upper back latissimus dorsi and trapezium flap are still the most reliable approaches, while perforator flaps based either on the circumflex scapular arteries or the transverse cervical artery represent a more refined option. In the middle third, few indications remain for the reverse latissimus dorsi, while the gold standard is represented by local perforator flaps based on the posterior intercostal system. In the lower back, conventional VY advancement flaps are still a safe and effective option in the sacral area, and perforator flaps based on posterior intercostal arteries, lumbar arteries and superior gluteal arteries are the first choice in most cases. Using perforator flaps significantly improved soft tissue reconstruction in the posterior trunk.