Advancement Flap Research Articles

Reconstruction of retroauricolar surgical defect using the "jigsaw puzzle" advancement flap.

We present the case of a 55-year-old male patient who came to our attention because of a basal cell carcinoma of the right retroauricolar area, near the mastoid-auricle border. The tumor had a size of about 1.5 cm. Repairing retroauricolar surgical defects may be actually very challenging, firstly because an incorrect reconstruction may result in severe deformities which are extremely hard to conceal; so, we decided to employ the "jigsaw puzzle" advancement flap, a versatile flap, firstly successfully used in the reconstruction of a nasal ala defect.

Role of the otologist/neurotologist in managing auricular and periauricular cutaneous malignancies: A 10-year otologic oncology experience.

Auricular/periauricular cutaneous malignancies can be challenging to manage surgically due to the complex anatomy of the region. Otologists/neurotologists have unique skillsets that are well-suited to surgically treat these patients. We aim to highlight the role of otologists and neurotologists in providing surgical care of patients with auricular and periauricular malignancies by describing the experience of a single fellowship-trained neurotologist over a 10-year period. Retrospective chart review of 387 patients with auricular and periauricular malignancy treated by a single neurotologist between 2012 and 2022 was completed. Tumor histology and procedures performed for each patient were extracted. Additional data was collected for a subset of 84 patients with complex cases requiring selective neck dissection, parotidectomy, lateral temporal bone resection, regional advancement or rotational flap reconstruction, and/or free tissue transfer reconstruction. Within the series of 387 patients, squamous cell carcinoma was the most common histology (42.6%, n = 165), followed by basal cell carcinoma (40.8%, n = 158), and melanoma (9.8%, n = 38). Common surgical procedures included wide local excision (61.8%, n = 239), partial/sub-total auriculectomy 18.3% (n = 71), or total auriculectomy 5.2% (n = 20). Within the 84-patient subset, median age at diagnosis was 71.9 years. Dermatologists provided most patient referrals (50.0%, n = 42). Most common tumor locations included: auricular (58.3%, n = 49), pre-auricular (21.4%, n = 18), and parotid (27.4%, n = 23). Revision surgery occurred in 22.6% of cases (n = 19), of which 26.3% (n = 5) for positive margins and 31.6% (n = 6) for recurrence. Mean follow-up was 22.8 months. Disease-specific 5-year survival was 91%. We demonstrate the feasibility of an otologist/neurotologist incorporating the surgical management of auricular and periauricular malignancies into their practice. 4.

Partial sternectomy with reconstruction of a giant cell tumor of the sternum, a case report, Saudi, Arabia

BackgroundGiant cell tumor (GCT) is a relatively common and locally aggressive benign bone tumor that rarely affects the sternum.Case presentationWe report a case of giant cell tumor of the sternum in a 28-year-old Saudi with painful swelling at the lower part of the sternum. Subtotal sternectomy and reconstruction with a neosternum using two layers of proline mesh, a methyl methacrylate prosthesis, and bilateral pectoralis muscle advancement flaps were performed.ConclusionsGiant cell tumor of the sternum is a rare diagnosis. Surgical resection with negative margins is the ideal management. To avoid defects or instability of the chest wall, reconstruction of the chest wall with neosternum should be considered.

A new volume-stable collagen matrix (VCMX) to treat single gingival recession associated with partially restored non-carious cervical lesions: a case series.

Collagen matrixes have been developed as possible connective tissue graft substitutes to overcome patient discomfort, undesired palatal healing, and the limited amount of donor tissue. The aim of this case series is to assess a coronally advanced flap (CAF) with a new volume-stable collagen matrix (VCMX) to treat single gingival recession (GR) associated with partially restored non-carious cervical lesions (NCCL). Twelve patients diagnosed with single GR RT1 + NCCL (B+) were included in this study and received a restorative - partial resin composite with apical margin 1 mm beyond the estimated cementoenamel junction (CEJ) - and a surgical approach - CAF+VCMX. Clinical and patient-centered assessments were recorded at baseline and 6 months postoperatively from ten patients. Significant recession reduction (RecRed:2.1mm), clinical attachment level gain (CAL:1.34mm), and combined defect coverage (CDC) of 51.67% were observed at 6 months. The estimate root coverage (RC) was 69.48%, obtained using the estimated CEJ. No difference in keratinized-tissue width (KTW) was observed over time. A gain in gingival thickness (GT) of 0.42 mm was observed after 6 months (p=.002) and an improvement in patient satisfaction due to better esthetics (p<.001). Within the present study's limits, CAF plus VCMX provided significant improvement in treating single GR combined with partially restored NCCL (B+).

Considerations for Selecting Root Coverage Techniques in the Anterior Mandible.

The anterior mandible is the most challenging anatomical site for performing periodontal plastic surgeries. Increased demands for optimal root coverage and esthetic outcomes contribute to the development of pedicle flap-based surgical solutions, in contrast to the predominantly used free gingival graft. The aims of this study were to (1) summarize the current literature to identify the mostused techniques, indications, and their efficacy, and (2) provide a decision table for surgeons to navigate through the selection of appropriate techniques. Four main approaches were identified: free gingival graft, lateral sliding, tunneling, and coronally advanced flap. The flap approaches are mostly combined with a connective tissue graft. The decision table considers the patient's chief complaint, local anatomical factors, and technique sensitivity. The table provides a framework for supporting an evidence-based selection of surgical techniques and for studying novel methods to achieve predictable root coverage in the anterior mandible.

Role of Microbiome in the Outcomes Following Surgical Repair of Perianal Fistula: Prospective Cohort Study Design and Preliminary Results.

Anal fistulae are common, predominantly cryptoglandular, and almost invariably require surgical treatment. Recurrences are common for procedures other than fistulotomy regardless of technique and adequacy of repair. Growing evidence supports the pivotal role of specific intestinal bacteria in anastomotic failures after bowel resection. Anal crypts harbor colonic microbiota suggesting that similar mechanisms to anastomotic healing might prevail after anal fistula repair and hence influence healing. This study aims at assessing the potential role of the intestinal microbiome in the clinical outcomes after surgical repair of cryptoglandular anal fistula. This is a pilot prospective cohort study enrolling patients with anal fistula undergoing endoanal advancement flap. For microbiome analysis, stool samples are taken via rectal swab before the procedure; additionally, a portion of the fistula is collected intraoperatively after fistulectomy. Samples from groups with treatment failure are compared to samples from patients who healed after surgical repair. Alpha and beta diversities and differential abundance of microbial taxa are determined and compared between groups with DADA2 analytical pipeline. Five patients have been enrolled to date (one female, four male). At median follow-up of 6months (2-11), one patient experienced disease recurrence at 3months. DNA from the 5 rectal swab and tissue samples was extracted, showing increased relative abundance of Enterococcus faecalis in samples from the patient who developed a recurrent fistula but not in those without recurrence. These very preliminary data suggest that intestinal microbiome may represent a crucial determinant of the surgical outcomes after anal fistula surgery.

THU524 Combination Of Mustardé Cheek Advancement Flap And Paramedian Forehead Flap As A Reconstructive Option In Basal Cell Carcinoma Of The Nose: A Functional And Aesthetic Alternative

Abstract Disclosure: A.P. Solis Pazmiño: None. C. Rocha: None. E. Pilatuna: None. R. Godoy: None. C. Garcia: None. Background: Defects resulting from the surgical procedure due to basal cell carcinoma (BCC) may be challenging to reconstruct depending on the size and location. In moderate to large-sized defects, especially in face lesions, a combination of more than one type of flap might be necessary. We present a patient with a large BCC in the nasal region which was successfully closed using a combination of rotation and advancement flaps. The patient showed excellent functional and cosmetic outcomes. Clinical Case: An elderly woman presented to our center with a five-year history of a persistent nasal vestibular lesion. It was treated with multiple cauterizations without a total improvement, until then. There was no associated pain, bleeding, or drainage. She denied family history, risk factors, or systemic diseases associated with this skin pathology. Physical examination revealed a 4 cm x 3 cm desquamated plaque with multiple pustules and a small deep ulcered area on the left nasal vestibule and overlying telangiectasia. A skin biopsy confirmed the clinical suspicion that this patient had nodular basal cell carcinoma (BCC), also known as rodent ulcer. The patient underwent surgery and we sent an intraoperative frozen section (IFS), 6 margins were taken in 10 mm strips each, and two of the seven tissue samples were reported positive. Made do with a double scalpel blade numbered by segments following clockwise order.Meanwhile, the defect reconstruction was done after histopathological examination confirmed tumor-free margins. A local skin flap, a paramedian forehead flap, transferred full-thickness skin and subcutaneous tissue into the surgical defect, which maintained the local blood supply via a vascular pedicle that remained connected to the donor site. Then, the advancement bilateral flap (Mustardé) was slid into the defect where the incisions were made tangentially to the defect to free neighboring tissue, with the wound edge acting as the free margin of the flap. Finally, for the frontal opening graft tissue, we used a pressure dressing on cutaneous grafts using a gauze wad (Brown Curative). Clinical lessons: This case exposes basal cell carcinoma (BCC), the most common skin malignancy with a predilection on sun-exposed areas such as the face. The surgical technical selected was a combination of skin flap techniques such as paramedian forehead flap, and the cheek rotational (Mustardé) flap showed excellent functional and cosmetic outcomes. Also, the oncological accepted margins depend on the risk group and the tumor size. For primary well-demarcated BCCs smaller than 2 cm, in the low-risk group, a safety margin of 3 mm gives satisfactory results. Presentation: Thursday, June 15, 2023

How We Do It: Alar Advancement Flap for Small Medially Based Alar Defects.

How We Do It: Alar Advancement Flap for Small Medially Based Alar Defects.

Efficacy of concentrated growth factor (CGF) in the surgical treatment of oral diseases: a systematic review and meta-analysis

BackgroundConcentrated growth factor (CGF), a new autologous platelet concentrate, has been widely investigated to the adjunctive treatment of oral diseases. This study aims to evaluate the efficacy of CGF in the surgical treatment of oral diseases.MethodsMEDLINE, Web of Science, Scopus, Cochrane, and EMBASE databases were searched up to July 2023. Only randomized clinical trials were included. The methodologic quality was evaluated by the Cochrane Risk of Bias Tool. RevMan 5.4 software was used for data analysis.ResultsIn the treatment of periodontal intrabony defects, bone graft combined with CGF was significantly superior to bone graft (P < 0.01), with mean intrabony defect depth reduction of 1.41 mm and mean clinical attachment level gain of 0.55 mm. In the regenerative surgery of furcation defects, the effect of CGF group was significantly better than control group (P < 0.0001), with mean probing depth reduction of 0.99 mm, vertical bone gain of 0.25 mm, and horizontal bone gain of 0.34 mm. CGF combined with coronally advanced flap (CAF) was more effective than CAF alone (mean keratinized tissue width increase of 0.41 mm, mean gingival thickness increase of 0.26 mm, P < 0.00001), but less effective than connective tissue graft (CTG) combined with CAF (mean root coverage difference of -15.1%, mean gingival thickness difference of -0.5 mm, P < 0.0001). In the alveolar ridge preservation, additional use of CGF reduced horizontal bone resorption by 1.41 mm and buccal vertical bone resorption by 1.01 mm compared to control group (P < 0.0001). The VAS score of CGF group was significantly lower than that of the control group at the 1st and 7th day after oral surgery (P < 0.0001).ConclusionsCGF can exert a positive adjunctive effect for the regenerative surgery of periodontal intrabony defects, furcation defects, and alveolar ridge preservation procedure. CGF combined with CAF has a better therapeutic effect on gingival recession compared to CAF alone, although it is not as effective as CTG combined with CAF. CGF could promote postoperative healing and pain relief in oral surgery within a week. There is currently not enough evidence to support the clinical benefits of CGF in other oral surgeries.

Mixed Dentition Period Follow-up of Primary Unilateral Cleft Nose Deformity Repair.

Recently, there has been an increased acceptance of the primary cleft rhinoplasty providing acceptable outcomes. Nose reconstruction, and specifically cleft nose deformity, should be addressed based on this philosophy. The purpose of this study was to evaluate surgical outcomes during the mixed dentition period after primary surgery to address unilateral cleft lip nose deformity based on the proposed technique. This is a retrospective cohort study. Thirty-two primary complete unilateral cleft lip patients were operated on by a single surgeon using the V-Y-Z cleft rhinoplasty. This method combines a composite V-Y advancement flap with lateral Z-plasty. Data collection was accomplished by evaluation of nasal symmetry through anthropometric measurements performed under general anesthesia during primary cleft palatoplasty and alveolar bone graft. The outcomes were evaluated through anthropometric measurements of the repaired nose during the mixed dentition period of follow-up, and no type of presurgical management was performed for any of the patients. Total nasal symmetry has been observed in 34.37% of patients at 7 years or more and 40.62% at 1-year follow-up. Nonstatistically significant differences were observed during follow-up, and major revision requirement (>3 mm of asymmetry in any of the nose measurements) was observed in 9.37% of patients. The proposed primary cleft rhinoplasty is a good approach to improve nasal appearance in patients with complete unilateral cleft lip and palate.

Coronally advanced flap in conjunction with hyaluronic acid application to treat localized gingival recession

Coronally advanced flap in conjunction with hyaluronic acid application to treat localized gingival recession

Homodigital Unipedicled Islanded Neurovascular Pulp Advancement Flap/Colombo Flap for Fingertip Reconstruction: A Case Series with a Novel Technique.

Fingertip injury is the most common type of upper extremity injury. Operative treatment with flap cover is required for tissue loss causing bone exposure and when there is a compelling need to preserve the length, unless microvascular replantation is possible. There are many techniques described for this purpose offering varying degrees of good outcomes. Yet there are limitations and long-term problems. We report a case series with a novel technique named "Colombo flap," which is a neurovascular islanded advancement flap based on a single pedicle. Five fingers of four consented patients were operated using this technique and they were followed up for 2.5 years. All had satisfactory sensory recovery (S3 +/S4), preserved range of motion (ROM) at interphalangeal joints, good grip strengths, and satisfactory outcomes based on Michigan Hand Questionnaire (MHQ). There were no complications such as flap necrosis, infection, and neuroma formation. Hook nail deformity was minimal and none had pain or cold intolerance.

Treatment of Deep Intrabony Defect with Buccal Gingival Recession using Connective Tissue Graft Combined with Enamel Matrix Derivative and Bone Graft: case reports

&lt;p&gt;It is a challenging situation for clinicians in managing deep non-contained intrabony de&amp;not;fects associated simultaneously with soft tissue recession nowadays. Besides, prevention of post-operative gingival recession is one of treatment goals for ideal regenerative surgery as well. The case reports tended to achieve periodontal regeneration and root coverage in teeth affected with both deep intrabony defects and the buccal gingival recession using the concept of connective tissue (CTG) wall technique combined with enamel matrix derivative (EMD) and bone graft materials. The surgeries involved a single flap approach (SFA) and augmentation of soft tissue, attempting to minimize post-operative gingival recession, by suturing the CTG on the inner surface of coronally advanced flap (CAF) as a barrier wall for the coronal portion of the bone defect. The bony defects were filled with allograft and/or xenograft as a space mak&amp;not;ing scaffold and followed by primary closure of wound. Significant probing depth (PD) reduc&amp;not;tion, clinical attachment level (CAL) gain and improvement in the level of gingiva margin were noticed after 7- and 11- months follow-up respectively. Comparisons of pre-operative and different periods of radiographic images demonstrated that the bone defects were indeed filled. It can be concluded that the CTG does support the bone regeneration and overlying soft tissue flap stability within the periods of observation. This surgical approach provides an alter-native aid on the clinical outcome of bone healing and root coverage simultaneously in deep intrabony defects.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Surgical Outcomes in Patients Treated with 5-Day Preoperative Radiotherapy for Soft Tissue Sarcoma

Treatment for high-risk soft tissue sarcoma (STS) of the extremity/trunk includes radiation therapy (RT) and surgical resection. Initial results of a phase 2 single arm trial of 5-day preoperative RT demonstrated acceptable safety and local control. Here we report an update of detailed surgical outcomes among patients treated with 5-day preoperative RT alone on the original phase 2 study, as well as an ongoing expansion cohort. We conducted an updated analysis of surgical complications from a previously reported phase 2 trial of 50 patients with high-risk extremity/trunk STS treated with 5-day preoperative RT (30 Gy over 5 consecutive daily fractions) and surgery. The current analysis includes additional patients from an ongoing IRB-approved expansion cohort of the phase 2 study, which was designed to compare wound complication rates between patients receiving neoadjuvant chemotherapy and those receiving RT alone. However, given that the primary endpoint of this study has not matured, here we present only the data for patients treated with 5-day preoperative RT alone (n = 44; data cutoff date: February 17, 2022). We generated a secure prospective patient database and extracted data including demographic variables, cancer characteristics and surgical outcomes. Minimum post-operative follow-up was 90 days. Statistical analysis was performed using R (v4.2). From a total of 94 patients, mean age was 57 (17-90), 40 (42.5%) were female, 10 (10.6%) were diabetic and 8 patients (8.5%) were active smokers or had a >10 pack-year smoking history. Median follow up was 24 months (IQR 10.6-41.8). The most common histologic diagnosis was undifferentiated pleomorphic sarcoma (n = 38, 40.4%). The most common location was the lower extremity (n = 57, 60.6%). Overall, 26 (27.7%) patients experienced surgical wound complications. In the lower extremity, wound complications occurred in 18 patients (31.6%). In all other sites, wound complications occurred in 8 patients (21.6%) (p = 0.41). Twenty-seven (28.7%) cases required local tissue advancement for primary closure and 12 of these patients (44.4%) experienced a wound complication (p = 0.04). Wound dehiscence occurred in 18 patients at a median duration of 43.5 days (IQR 40.3-85.3) from surgery, comprising 69.2% of all wound complications. Secondary surgical intervention was required in 28 patients (29.8%), of which 7 were oncologic re-excisions and 15 were irrigation and debridement. On multivariate analysis, the use of advancement flaps (OR = 5.39; p = 0.004) and diabetes (OR = 4.08; p = 0.07) were associated with wound complications. Five-day preoperative RT for STS results in rates of wound complications comparable to standard fractionation. We identified local advancement flaps as the primary factor associated with wound complications. STS of the lower extremity that require complex closure warrant close attention for dehiscence.

Aesthetic subunit reconstruction of basal cell carcinoma face

Background: Arising from the basal cell layer of epidermis; BCC is one of the most common cutaneous malignancy encountered in elderly (77%) followed by SCC (20%) and malignant melanoma (3%). Method: A prospective observational study was conducted at department of plastic and reconstructive surgery with 50 patients included for over a span of 2 years. Patients with biopsy confirmed BCC lesion over face were included and were grouped on the basis of subunit involved and type of flap done. Results: The 50 patients were included which comprised of 16(32%) males and 34 (68%) females. Mean age was 61±10.2 years. Smallest defect size was of 1.5 cm2 whereas largest defect size was of 5 cm2. Cheek was the most common site of occurrence. Cheek advancement flap was the most commonly performed flap. Conclusions: Reconstruction of facial subunit post BCC excision with local tissue has superior aesthetic outcome in terms of colour and texture than any other modality.

Burow’s triangle advancement flap: a reliable oncoplastic surgery for upper/upper inner quadrant breast cancer

The oncologic outcome of breast-conserving surgery (BCS) is equivalent to mastectomy, when free margins are achieved and adjuvant radiotherapy of the operated breast is applied. Oncoplastic breast conserving techniques combine two aspects: oncological safety with a resection of the tumor with free margins and optimal aesthetic aspects. The modified Burow’s triangle advancement flap for upper/upper Inner quadrant breast cancer is a safe and effective technique to manage tumors at this complex location. It provides adequate oncological margins, good cosmetic results, and contralateral symmetry, with complication rates similar to those of standard conservative surgery.

Transversus abdominis release with biosynthetic mesh for large ventral hernia repair: a 5-year analysis of clinical outcomes and quality of life.

Transversus abdominis release (TAR) may provide an optimal plane for mesh placement for large ventral hernias requiring medial myofascial flap advancement. Long-term outcomes of TAR for large ventral hernia repair (VHR) remains under-studied. This study aims to assess longitudinal clinical outcomes and quality of life (QoL) following large VHR with TAR and resorbable biosynthetic mesh. Retrospective review of clinical outcomes and prospective QoL was performed for patients undergoing VHR with poly-4-hydroxybutyrate mesh and TAR from 2016 to 2021. Patients with ≤ 24months of follow-up, defects ≤ 150cm2, and parastomal hernias were excluded. Cost-related data was collected for each patient's hospital course. QoL was compared using paired Wilcoxon signed-rank tests. Twenty-nine patients met inclusion criteria. Median age and BMI were 61years (53.2-68.1years) and 31.4kg/m2 (26.1-35.3kg/m2). Average hernia defect was 390cm2 ± 152.9cm2. All patients underwent previous abdominal surgery and were primarily Ventral Hernia Working Group 2 (58.6%). Two hernia recurrences (6.9%) occurred over the median follow-up period of 63.1months (IQR 43.7-71.3months), with no cases of mesh infection or explantation. Delayed healing and seroma occurred in 27 and 10.3% of patients, respectively. QoL analysis identified a significant improvement in postoperative QoL (p < 0.005), that continued throughout the 5-year follow-up period, with a 41% overall improvement. Cost analysis identified the hospital revenue generated was approximately equal to the direct costs of patient care. Higher costs were associated with ASA class and length of stay (p < 0.05). Large VHR with resorbable biosynthetic mesh and TAR can be performed safely, with a low recurrence and complication rate, acceptable hospital costs, and significant improvement in disease-specific QoL at long-term follow-up.

Primary management of the inframammary fold in breast reconstruction using the thoracoabdominal advancement flap: Surgical technique

Our experience in breast reconstruction confirms the significant importance of reconstructing the inframammary fold in achieving overall aesthetic satisfaction. We describe our technique for primary fixation of the inframammary fold in breast reconstruction using a thoracoabdominal advancement flap. This technique is suitable for patients with a vertical skin laxity of at least 5cm in the future inframammary fold. Prior to the procedure, it requires preparation through physiotherapy, the use of adhesive external breast prosthesis, and skin expansion using an inflatable prosthesis in extreme cases. The surgical approach follows the existing mastectomy scar. After subfascial dissection of the thoracoabdominal advancement flap, the surgeon proceeds to create two separate rows of sutures. The first row mimics the deep attachment of the inframammary fold, fixing the superficial fascia of the flap to the rib periosteum. The second row mimics the superficial attachment of the inframammary fold, fixing the dermis of the flap to the rib periosteum. The main advantage of this technique is its applicability to all breast reconstruction programs.

LINEAR CLOSURE: A STRAIGHTFORWARD APPROACH TO LARGE DEFECTS ON THE NASOLABIAL CHEEK FOLLOWING MOHS MICROGRAPHIC SURGERY FOR MORPHEAFORM BASAL CELL CARCINOMA

Mohs micrographic surgery (MMS) utilizes intra-operative histological assessment to maximize clearance of cutaneous malignancy while minimizing surgical defect size. [1–4] On cosmetically sensitive areas, most notably the face, transposition, advancement, and interpolation flaps and occasionally skin grafts are often utilized as repair techniques, despite potential for post-operative complications including bleeding, infection, impaired wound healing, and graft/flap loss.[1–5] Here we present a case of a large (6.5 cm by 3.5 cm) surgical defect on the cheek following MMS for the management of a morpheaform basal cell carcinoma and briefly review considerations regarding closure repairs, emphasizing linear closure as a reliable and successful option.

Nasal columella reconstruction using philtrum advancement flap: a case report of treatment of nasal stenosis

BackgroundNasal columella reconstruction is a challenging procedure, and the main goal is to maintain function as well as a satisfactory aesthetic outcome. Several surgical techniques have been described for the reconstruction of nasal columella. However, there is a paucity of literature on these techniques in our environment, and the use of superiorly based philtrum advancement flaps is extremely rare in African literature.Case presentationA 60-year-old man presented with nasal obstruction and nasal deformity following facial trauma 6 months prior to presentation. Examination revealed bilateral stenosed nasal cavities and a very short columella with a healed nasal scar. The diagnosis of nasal stenosis was made. Intra-operatively, a superiorly based philtrum advancement flap was designed and elevated, granulation tissues in the nasal cavities were excised, the septum was repositioned, the base of the flap was sutured at the midline of the floor of the nose, and the donor site was approximated. A bilateral nasal stent was applied for 4 weeks. Postoperatively, the recipient and donor sites healed completely with an aesthetically acceptable appearance, and the patient was satisfied with the outcome.ConclusionNasal columellar reconstruction is a complex procedure. The superiorly based philtrum advancement flap is a simple and aesthetically acceptable method of treating nasal stenosis. This method demonstrated an adequate nasal airway and a good cosmetic appearance.