Bridge Flap Research Articles

Increasing the Width of Keratinized Mucosa in Maxillary Implant Areas Using a Split Palatal Bridge Flap: Surgical Technique and 1-Year Follow-Up.

Sufficient soft-tissue coverage of maxillary implant sites may be difficult to achieve, especially after bone augmentation. The use of vestibular flaps moves keratinized mucosa (KM) toward the palate and may be disadvantageous for future peri-implant tissue stability. This study describes a new split palatal bridge flap (SPBF) that achieves tension-free wound closure and increases the KM width in maxillary implant areas. We began SPBF surgery with a horizontal incision in the palatal soft tissue to create a split-thickness flap. The second incision was performed perpendicular to the first, using a bridge design, at a distance of 10 to 15 mm. The superior layer can be moved crestally and sutured to cover the soft-tissue defect. The defect width was measured using a periodontal probe. The inferior layer was left exposed, and secondary wound healing created new KM in this region. This SPBF technique was performed on 37 patients. Of these, 16 patients were included in the assessment of clinical peri-implant outcomes. All of the SPBF procedures successfully resulted in a palatal regeneration of KM through secondary wound healing (mean regeneration width, 4.51 ± 1.17 mm; range, 3-6 mm). The 1-year follow-up of 16 patients revealed a mean pocket probing depth of 3.22 ± 0.6 mm with zero cases of peri-implantitis. The vestibular KM width at the involved implants was 2.82 ± 1.07 mm (range, 1.5-6 mm). Surgery for SPBF may be a promising technique for covering soft-tissue defects and increasing KM width in maxillary implant surgery.

Subtotal lower lid reconstruction from upper eyelid full thickness bridge flap with earlier 2(nd) stage surgery at 3 weeks.

Subtotal lower lid reconstruction from upper eyelid full thickness bridge flap with earlier 2(nd) stage surgery at 3 weeks.

Analytical and experimental study on aerodynamic control of flutter and buffeting of bridge deck by using mechanically driven flaps

A passive control using flaps will be an alternative solution for flutter stability and buffeting response of a long suspension bridge. This method not only enables a lightweight economic stiffening girder without an additional stiffness for aerodynamic stability but also avoid the problems from the malfunctions of control systems and energy supply system of an active control by winglets and flaps. A time domain approach for predicting the coupled flutter and buffeting response of bridge deck with flaps is investigated. First, the flutter derivatives of bridge deck and flaps are found by experiment. Next, the derivation of time domain model of self-excited forces and control forces of sectional model is reported by using the rational function approximation. Finally, the effectiveness of passive flap control is investigated by the numerical simulation. The results show that the passive control by using flaps can increase the flutter speed and decrease the buffeting response. The experiment results are matched with numerical ones.

Root coverage with bridge flap

Gingival recession in anterior teeth is a common concern due to esthetic reasons or root sensitivity. Gingival recession, especially in multiple anterior teeth, is of huge concern due to esthetic reasons. Various mucogingival surgeries are available for root coverage. This case report presents a new bridge flap technique, which allows the dentist not only to cover the previously denuded root surfaces but also to increase the zone of attached gingiva at a single step. In this case, a coronally advanced flap along with vestibular deepening technique was used as root coverage procedure for the treatment of multiple recession-type defect. Here, vestibular deepening technique is used to increase the width of the attached gingiva. The predictability of this procedure results in an esthetically healthy periodontium, along with gain in keratinized tissue and good patient's acceptance.

Lateral sliding bridge flap technique along with platelet rich fibrin and guided tissue regeneration for root coverage

Gingival recession is defined as the apical migration of the gingival margin with exposure of root surfaces. The etiology of the condition is multifactorial. Given the high rate of gingival recession defects among the general population, it is imperative that dental practitioners have an understanding of the etiology, complications and management of the condition. A recent innovation in dentistry is the preparation and use of platelet-rich fibrin (PRF) for recession defects. The article presents a case report, which highlights the use of lateral sliding bridge flap along with PRF in a collagen membrane carrier (guided tissue regeneration) for the treatment of multiple recession defects.

Skin bridge versus rod colostomy in children - comparison between complications.

Due to economic problems, sigmoid loop colostomy using glass rod may cause problems for our patients for finding glass rod and several visits. The aim of the study was to compare rod versus skin bridge colostomy. In this study, 42 cases who are candidate for colostomy were included. Cases were randomly placed in skin bridge and rod colostomy group. Independent sample t-test and Chi-square were used for comparison. SPSS version 16.0 (SPSS Inc, Chicago, IL, USA) was used for analysis. Of 42 cases, 20 were male and 22 were female. Hirschsprung's disease was the indication of colostomy in 33 cases. In nine cases, imperforate anus was the indication of colostomy. Mean time of surgery was 79.4 and 82.5 minute for the rod and skin bridge group respectively (P>0.05). Retraction was seen in 2 case of rod group, and no case of skin bridge group. Prolapse was seen in 2 (9.5%) case of rod group and 1(4.7%) case in skin bridge. There were no reports of necrosis, stenosis, and hernia in both groups. In the skin bridge group the rates of complications were lower but the groups are too small for statistical analysis. Colostomy with a skin bridge method may decrease number of revision and expenses and may be appropriate option. Sigmoid loop colostomy using skin bridge flap may be appropriate choice in developing country. Another study with more samples is recommended to better comparison of Skin Bridge versus rod colostomy.

Nevoid Basal Cell Carcinoma Syndrome

Figure 1: Clinical photograph showing frontal bossing and mutiple milia on forehead; Figure 2: Broad nasal root, linear ulcerated pigmented lesion on lower lid of right eye; Figure 3: Multiple pigmented lesions on face and neck; Figure 4: Clinical picture showing multiple palmer pits; Figure 5 (a,b,c): Hughes tarsoconjuctival bridge flap procedure with post auricular skin grafting (stage 1); Figure 5 (d): Clinical photograph after division of tarsoconjunctival flap (stage 2); Figure 6: Histopathological picture showing features of basal cell carcinoma. (Thin arrow-basaloid cells, thick arrow-palisading)

Double Lateral Sliding Bridge Flap for the Treatment of Multiple Gingival Recessions: Case Series

Esthetic concerns of patient have become an essential part of dentistry, especially periodontics. Root coverage is being achieved by a variety of surgical techniques. The presence ofshallow vestibule, inadequate width of attached gingiva and aberrant frenum pull may pose a challenge to cover the denuded root surface for which several independent surgical solutions are reported in the literature. This article highlights on two case reports in which a double lateral sliding bridge flap technique has been used for root coverage as a single step solution for the above mentioned mucogingival problems, if present simultaneously in any case.

Ischemia and intersecting stapling: the Achilles’ heel of problematic low rectal anastomoses

It is well known that low rectal anastomoses are associated with an increased number of anastomotic leaks, even if well-established principles of bowel anastomosis are strictly adhered to, such as avoiding tension of adapting tissues, preserving adequate tissue vascularization and ensuring the anastomosis watertight, with potentially disastrous consequences for patients. Although many risk factors related to anastomotic disruption have been identified, the mechanisms leading to stapling line failure for low rectal anastomoses have not yet been well defined. Colonic J-pouch construction after low anterior resection is now common practice because of the larger capacity of the J-pouch and the improvement in anorectal function in the early postoperative period. This procedure involves two longitudinal enterotomies on the same segment of the intestinal wall. A bowel wall bridge flap is then formed and the blood perfusion of the flap will inevitably be further compromised, which may contribute to leakage of the pouch-anal anastomosis, fistula formation, and stricture at the pouch-anal anastomosis (Fig. 1). It is a common precept from anatomy that no double-parallel longitudinal incisions should be made on the same segment of the intestinal wall. An incomplete staple line may be created when crossoverlap stapling is used after a double-stapling technique. Staples being driven into other staples may be one of the potential adverse events related to the double-stapling technique. When a double-stapling technique is adopted and the staples of the second circular stapler are driven into tissue under the pressure created by closing the stapler, some of the staples will hit the B-formed staples made by the former linear stapler and will never reach the anvil or will fail to completely puncture the tissue, especially in tangential or acute angle cross-overlapping stapling (Fig. 2a–c). The current thickness of the titanium wire used for staples is normally 0.2–0.3 mm. The probability that staples will strike other staples is low, even if the original staples have been buckled or bent into the final B shape, although this adverse event has not been proven by experiments. Therefore, in our opinion, intersecting staple lines should be used as sparingly as possible, and if they must be used, they should be placed at right angles to

A New Route for Passing a Free Flap Vascular Pedicle Using Contralateral Facial Vessels as Recipient Vessels in Skull Base Reconstruction

A New Route for Passing a Free Flap Vascular Pedicle Using Contralateral Facial Vessels as Recipient Vessels in Skull Base Reconstruction

The use of acellular human dermis composite graft for upper eyelid reconstruction in ocular injury

Repair of the upper lid is more difficult because of the unique anatomic requirements of the upper eyelid. The eyelid must remain pliable, allow for retraction and protraction, and also have a mucous membrane on the posterior surface. A number of procedures are available to repair large to total upper eyelid defects. These surgical techniques include lower lid switch flaps and lower lid bridge flaps. However, these procedures have several disadvantages, such as the partial or total sacrifice of the lower lid and the need for secondary correction. The authors present a new surgical technique using composite graft of acellular dermis and split-thickness buccal mucosa in the reconstruction of traumatic full-thickness upper eyelid defects to achieve satisfactory functional and esthetic results. In this retrospective case series, eight patients requiring full-thickness upper eyelid reconstruction were evaluated. Defect size ranged from 20 mm to 28 mm horizontally and from 5 mm to 8 mm vertically. For eyelid reconstruction, the acellular dermis composite graft was sutured into the posterior lamella defect; the anterior lamella was repaired with a bipedicled orbicularis flap and a free skin graft. Acellular dermis composite grafts achieved complete resolution of lagophthalmos and follow-up of 6 months to 31 months revealed a good outcome in all eight cases. No adverse situation of the grafts viability was encountered. Postoperative complications occurred in two patients; one had eyelid margin notching and the other had a mild ptosis. The acellular dermis composite graft is a good match for the posterior lamella of the eyelid in terms of texture and contour. The acellular dermis composite graft technique is useful for the reconstruction of large upper eyelid defects resulting from burns or trauma because this method results in complete repair of defects without causing notable deformity.

Dry Eye Symptoms in Patients after Eyelid Reconstruction with Full-Thickness Eyelid Defects: Using the Tomey TG-1000 Thermographer

Background: Large full-thickness eyelid defects are conventionally reconstructed by either a Hughes flap or Cutler-Beard bridge flap. Since the structure of the eyelid and its components are necessary for the tear film production and stability, we investigated the outcome after eyelid reconstruction focusing on dry eye symptoms using a new thermographic device, the TG-1000. Methods: Seventeen eyes of patients formerly treated with Hughes flaps (n = 16) and a Cutler-Beard bridge flap (n = 1) were compared to untreated healthy eyes (n = 17) regarding the functional and aesthetic outcome. The follow-up ranged from 3 to 63 months (mean 24.88 ± 17.86). Results: There was no significant difference in Schirmer’s test, break-up time and ocular surface temperature (p > 0.05) between patients after full-thickness eyelid reconstruction and a control group. Eleven patients had minor postoperative complications such as notching of the lid margin (11/17), epiphora (1/17), superficial punctate keratitis (6/17), trichiasis (2/17) and a mild tendency to eversion of the lid margin (6/17). More than 75% of the patients rated their postoperative aesthetic outcome as good or even excellent. Conclusion: The new TG-1000 device is a simple and quick tool for screening of dry eye. This study shows that tarsoconjunctival grafts offer good aesthetic and functional outcome with sufficient tear film composition and stability.

Closure of nasal septum perforations by bridge flaps

IntroductionTreating nasal septum perforation is challenging from every point of view for patients who suffer from this condition. This article presents a general overview of this topic and describes an operative technique that very often enables closure of the perforation. Materials and methodsA retrospective and descriptive study was performed on 92 patients who were surgically treated for nasal septum perforation. All patients were treated with the three-layer bridge flap technique for closure of the defect. ResultsIn 98% of the patients, primary closure of the septum perforation was achieved immediately after removing the silicone sheets. The closure rate 18 months postoperatively was 93.8% (60 of the 64 patients who were examined postoperatively). ConclusionsSuccess in closure of the septum perforation was greater than 90% with the 3-layer bridge flap technique. This technique can be performed using an endonasal approach and offers fewer complications in experienced hands. The limitation of this procedure is the height of the perforation.

Bridge flap technique as a single-step solution to mucogingival problems: A case series

Shallow vestibule, gingival recession, inadequate width of attached gingiva (AG) and aberrant frenum pull are an array of mucogingival problems for which several independent and effective surgical solutions are reported in the literature. This case series reports the effectiveness of the bridge flap technique as a single-step surgical entity for increasing the depth of the vestibule, root coverage, increasing the width of the AG and solving the problem of abnormal frenum pull. Eight patients with 18 teeth altogether having Millers class I, II or III recession along with problems of shallow vestibule, inadequate width of AG and with or without frenum pull underwent this surgical procedure and were followed-up till 9 months post-operatively. The mean root coverage obtained was 55% and the mean average gain in width of the AG was 3.5 mm. The mean percentage gain in clinical attachment level was 41%. The bridge flap technique can be an effective single-step solution for the aforementioned mucogingival problems if present simultaneously in any case, and offers considerable advantages over other mucogingival surgical techniques in terms of simplicity, limited chair-time for the patient and the operator, single surgical intervention for manifold mucogingival problems and low morbidity because of the absence of palatal donor tissue.

Cierre de las perforaciones del tabique nasal mediante colgajos «en puente»

Introduction Treating nasal septum perforation is challenging from every point of view for patients who suffer from this condition. This article presents a general overview of this topic and describes an operative technique that very often enables closure of the perforation. Materials and methods A retrospective and descriptive study was performed on 92 patients who were surgically treated for nasal septum perforation. All patients were treated with the three-layer bridge flap technique for closure of the defect. Results In 98% of the patients, primary closure of the septum perforation was achieved immediately after removing the silicone sheets. The closure rate 18 months postoperatively was 93.8% (60 of the 64 patients who were examined postoperatively). Conclusions Success in closure of the septum perforation was greater than 90% with the 3-layer bridge flap technique. This technique can be performed using an endonasal approach and offers fewer complications in experienced hands. The limitation of this procedure is the height of the perforation.

Modern Bone Regeneration Instead of Bone Transplantation: A Combination of Recombinant Human Bone Morphogenetic Protein-2 and Platelet-Rich Plasma for the Vertical Augmentation of the Maxillary Bone—A Single Case Report

This publication describes the clinical case of a 75-year-old woman. She suffered from total alveolar ridge atrophy due to 20 years of wearing dentures. Bone transplantation, including harvesting of the iliac crest, was rejected by another clinic due to various existing diseases and risk of blood loss on donor side. Moreover, the minimal residual alveolar ridge did not allow bone fixation using screws nor did it allow osteodistraction. Before deciding which bone tissue engineering techniques should best be employed in this surgical treatment, cardiological and internistic consultations and treatments were carried out. In addition, anesthetic preparations were made. The surgical treatment was performed implementing special bridge flap techniques to preserve the periosteum. Tricalcium phosphate blocks soaked with recombinant human bone morphogenetic protein-2 and platelet-rich plasma were implanted on the narrow alveolar ridge. They were attached by tightening the soft tissue, including the periosteum. Four months later, after complication-free wound healing and bone regeneration, six dental implants were inserted into the new alveolar ridge. The histology of all bone samples showed vital lamellar bone. Three months after implantation, a new dental structure was fixed on the implants. The patient's quality of life improved significantly with this new situation.

PR47 COMPREHENSIVE EYELID RECONSTRUCTION

Introduction The central focus of eyelid reconstruct is the reconstitution of a dynamic protective covering for the cornea. The key to successful eyelid reconstruction is to properly assess the size of the defect and to separate the complex defect down into component parts or subunits. Since eyelid tissues retract in the presence of discontinuity, the residual lid margin has to be distracted under normal tension in order to assess the true size of the defect. In surgical planning, one must also assess the amount and location of inner and outer lamellar tissue absent. The inner lamella represents the conjunctiva, the tarsal plate, and the tarsoligamentous sling. The primary function is to provide lining and support to the lid. The most important region to reconstruct the inner lamella, the conjunctiva in particular, is centrally over the cornea in the upper lid. The outer lamella is represented by the skin and orbicularis oculi muscle. In the upper lid, the outer lamella has functional importance by enabling the dynamic blink to protect the cornea and prevent exposure. Small reconstructions may be carried out as a single stage, larger ones may require more than one stage. The fundamental principle is to utilize the following techniques for defects of increasing complexity and/or size 1) primary closure, 2) adjacent tissue, 3) lid sharing, and 4) regional or distant flap.Methods/Technique Depending on the size of the defect, direct closure may be possible. Upper lids with a defect of 1/3 or less of the horizontal length can be closed directly. The criteria for lower lid direct closure is 1/4 to 1/3 of the horizontal length. Closure under too much tension will cause mechanical ptosis in the upper lid and lid retraction in the lower lid due to the close line effect. A selective (upper or lower) canthotomy will provide an additional 3–4 mm of length through tissue recruitment. The next order of reconstruction is the semicircular Tenzel skin muscle flap. This option is for subtotal defects greater than 1/3. Depending on the design, this flap can be used for upper or lower lid defects. By recruiting lateral tissue, end‐to‐end closure of the wound is achieved centrally, while the original defect undergoes lateralization. The absence of lashes laterally is better tolerated than centrally. The next order of reconstruction involves lid sharing. Upper lid tissue used for lower lid reconstruction includes the Hughes flap which shares a part of the upper lid tarsal plate and conjunctiva. Total upper lid reconstruction uses the lower lid Cutler‐Beard flap with ear cartilage to replace missing tarsal plate. Both the Hughes procedure and the Cutler Beard Bridge Flap are two‐stage procedures that are divided 2 weeks after the initial lid sharing. The visual axis is obstructed for two weeks until the bridge is divided. The Hewes’ flap is a single stage reconstruction lid sharing for lower lateral defects. It is based on the superior vascular arcade. Distant flaps such as the Tripier, Fricke, and forehead or glabelllar flaps are used for large defects when other options are not possible.Results Over the past 12 years 218 eyelid reconstructions were performed. 75% were cancer related and 25% were trauma related. 50% were secondary reconstructions referred from other surgeons. The average age of the patients was 60 evenly distributed between males and females. 90% of the cancer related defects were created by a Moh’s surgeon. Upper lid defects represented 25%and lower lid defects represented 75%. The distribution of procedures used is as follows: 25% direct closure (selective canthotomy was often employed for direct closure), 40% Tenzel flap, 15% lid sharing flaps, 10% Hewes flaps, and 10% distant flaps. Mucosal grafts were required for secondary cases of the upper lid. 10% of patients required a revision surgery (other than planned bridge division). The most frequent complications were lid malposition, excess lateral orbital skin, and need for lacrimal reconstruction with DCR, Jones’ tubes or Crawford tubes. Permanent corneal damage or rupture was prevented in all cases.Conclusion Eyelid reconstruction simplified by breaking complex defects into their component parts. Algorithmic linkage of reconstructive method to shape and size of defect also assist with consistent successful results. Eyelid reconstruction balances the functional result of the reconstructve procedures as well as the aesthetic result in order to minimize morbidity.

Combined Fibular Osteocutaneous and Omental Flaps

The free vascularized fibular bone graft, first described in 1975, has become one of the most commonly used bone grafts. It is useful for reconstructing mandibular and traumatic long bone defects and defects following tumor resection. This flap, however, does not have a long pedicle and does not have very much volume. The authors report a solution to these problems through the use of an omental flap as a bridge. Over a 3-year period, nine patients were treated by means of a free fibular osteocutaneous flap with an omental flap. These cases required bone reconstruction without suitable recipient vessels that existed near the defect. The nine patients had the following disorders: two femoral pseudoarthrosis, two tibial pseudoarthrosis, two malignant femoral tumors, one maxillary defect after tumor resection, and one femoral and tibial osteomyelitis. All flaps were transferred successfully. In one case, an additional skin graft was performed because of partial omental necrosis that occurred within 2 weeks. Fibular synostosis developed in eight cases, but amputation was performed in one case because of failed fibular synostosis. In one case, femoral amputation was performed because the femoral artery became obstructed 3 months postoperatively. An omental flap has a long pedicle for use as a bridge flap. It is useful as a vascular flap. A combined fibular osteocutaneous and omental flap is useful for bone reconstruction without satisfactory recipient vessels that exist near the defect. Furthermore, the flap is useful for infected wounds.

Chirurgie des Nasenseptums und der Nasenmuscheln

The following article presents nasal septum and turbinate surgery. First an overview with special consideration of the anatomical and physiological background is given followed by indications for surgical procedures. Key steps of the gold standard procedure first described by Cottle and common variations are presented. Furthermore, some techniques dealing with special problems of the septumplasty are discussed followed by an overview on complications and long term results. However, it should be mentioned that studies on surgical procedures of the nasal septum are still not sufficient as higher evidence levels are very rare. Within a separated chapter techniques for closure of septum perforations are presented and indications particularly in the background of the standard procedure of bridge flaps forwarded by Schultz-Coulon are discussed. The second part focusses on turbinate surgery. Accordingly, anatomical and physiological basics are presented followed by indications for surgical procedures and the surgical steps of different procedures as well as postsurgical treatment and long term results.

The Switch Flap in Eyelid Reconstruction

Purpose: Full-thickness eyelid defects are conventionally reconstructed by either a Hughes flap or a Cutler-Beard bridge flap. The switch flap is an alternative method and is not very widely practiced. The author has used this method for repair of large full-thickness eyelid defects and describes her experience with the use of this technique. Method: Eight cases of large full-thickness eyelid defects resulting from excision of tumours such as basal cell carcinoma (bcc), squamous cell carcinoma (scc) and sebaceous gland carcinoma (sgc) were taken for repair using the switch flap technique. The technique involves switching a full-thickness flap on a pedicle to fill a defect from lower lid to upper or vice versa. The pedicle is divided in three weeks. The recipient lid is reconstructed by direct closure and the donor lid by direct closure with or without cantholysis or sliding flap, or it is left to heal by second intention. The patients were followed up frequently in the first few weeks according to need, at six months, and then every year for five years before discharge. At these visits, contour of lid, condition of wound, cornea and donor site were examined for infection, dehiscence, corneal ulcer, notching, trichiasis, and recurrence. The preoperative and postoperative photographs were also compared. Results: Out of the eight cases of eyelid defects, one was from squamous cell carcinoma, three were from sebaceous gland carcinoma, and four were from infiltrative basal cell carcinoma. Using the switch flap technique, the defects resulting from their excision were completely covered in all cases. The main complication was a corneal ulcer in cases 1 and 3 where the flap had crossed the central cornea. A bandage contact lens was inserted until the division of the flap. The main morbidity was the blurred vision until the flap is divided, especially in the cases of reduced vision in the other eye. At about 4–6 weeks post flap division, the recipient and donor sites have healed completely, even when the donor lid was left to heal by second intention (case 4). There was no trichiasis, notching or notable deformity, and the morbidity was minimal. A comparison between preoperative and postoperative photographs shows satisfactory results with the switch flap technique. Conclusion: The author has found the switch flap technique very useful for reconstruction of large full-thickness eyelid defects resulting from tumour excision as this method results in complete repair of defects with a full-thickness flap, tarsus, lid margin and eyelashes and without causing notable deformity at the donor site. The switch flap can successfully replace the Hughes flap technique and Cutler-Beard technique for repair of large eyelid defects.