Closure Tension Research Articles

Colgajo obispo y colgajo sigma para defectos quirúrgicos en zonas anatómicas de elevada tensión

The reconstruction of surgical defects in high-tension anatomical regions is challenging due to the ischemia and subsequent necrosis associated with tension closure. Research on new flaps capable of closing these defects exerting less tension would be a tremendous advancement in dermatological surgery. We conducted a multicenter, retrospective study that used 2 new flaps-the bishop and the sigma ones-to repair surgical defects in high-tension regions such as the scalp, lower extremities, and the nasal pyramid. The bishop flap was used in 9 patients, 5 of whom exhibited their lesion in the nasal pyramid, 2 in the legs and another 2 in the scalp. The sigma flap was used in 6 patients, 5 of whom exhibited scalp lesions and 1 leg lesion. Uneventful and excellent results were obtained in all 15 patients due to infection, dehiscence, or necrosis. Both the bishop and the sigma flaps are a good alternative to repair surgical defects in high-tension regions such as the scalp, lower extremities, or the nasal pyramid.

Colgajo obispo y colgajo sigma para defectos quirúrgicos en zonas anatómicas de elevada tensión

The reconstruction of surgical defects in high-tension anatomical regions is challenging due to the ischemia and subsequent necrosis associated with tension closure. Research on new flaps capable of closing these defects exerting less tension would be a tremendous advancement in dermatological surgery. We conducted a multicenter, retrospective study that used 2 new flaps-the bishop and the sigma ones-to repair surgical defects in high-tension regions such as the scalp, lower extremities, and the nasal pyramid. The bishop flap was used in 9 patients, 5 of whom exhibited their lesion in the nasal pyramid, 2 in the legs and another 2 in the scalp. The sigma flap was used in 6 patients, 5 of whom exhibited scalp lesions and 1 leg lesion. Uneventful and excellent results were obtained in all 15 patients due to infection, dehiscence, or necrosis. Both the bishop and the sigma flaps are a good alternative to repair surgical defects in high-tension regions such as the scalp, lower extremities, or the nasal pyramid.

Exstrophy epispadias complex with adenocarcinoma in adults: a case series and repair technique

The exstrophy-epispadias-complex (EEC) is a rare congenital malformation with a spectrum of abdominal-pelvic fusion abnormalities, with an incidence of 1/46,000 LB. Recurrence is 1 in100 & the male-to-female ratio is 2.3:1. Patients rarely may present in adulthood due to a lack of knowledge or financial constraints; it increases the risk of bladder carcinoma mostly adenocarcinoma or squamous carcinoma, due to chronic inflammation, infection, and metaplasia. It has a significant physical, functional, social, sexual, and psychological burden. Three patients have been operated on in our institute. A 37-year-old male, A 19-year-old male, and A 23- year-old female patient. The operation planned was a radical cystectomy with an ileal conduit and an expanded local lymphadenectomy in all three patients. The pelvis and abdominal wall defects were repaired differently post-radical cystectomy in all 3 patients using different techniques. The first patient went through primary tension closure, in the second patient bilateral rectus muscle was used as a flap and reinforced with mesh, and in the third patient, we used a rotation skin flap. All three patients were followed for 1 year. The first patient developed wound dehiscence followed by fecal fistula during follow-up and succumb due to sepsis, the second patient recovered well with a muscle flap in the postoperative period, unfortunately, developed recurrence locally and succumb due to multiple metastases, and the third patient develops flap necrosis at the tip postoperative on day 5, however, recover well after dressing, no recurrence seen on 1 year of regular follow up. As a result, the bilateral rectus flap with mesh recovers better than the rotation skin flap, which is better than primary tension closure.

Diaphragmatic relaxing incisions for complex hiatal reconstruction: longer-term follow-up confirms safety, efficacy and rare complications.

Tension is an important factor in hernia repairs. Relaxing incisions to reduce tension are common with ventral hernia repairs, and techniques for relaxing incisions also exist for the hiatus. The aim of this study was to update our original experience with a diaphragm relaxing incision (DRI) in a larger group of patients with longer follow-up. A retrospective chart review was performed to identify all patients who had a DRI between August 2016 and September 2021 during hiatal hernia repair. All DRI defects were repaired with permanent mesh remote from the esophagus. Objective follow-up was with chest x-ray, upper GI series (UGI) or both. Seventy-three patients had a total of 79 DRI (right in 63, left in 4, and bilateral in 6 patients), during a primary (n = 52) or redo (n = 21) hiatal hernia repair. Concomitant Collis gastroplasty was used in 38 patients (52%). A single intra-operative complication occurred where the right crus tore during a right DRI. At a median of 15months, 78% of patients had objective follow-up. There was one hernia through a repaired right DRI (1.2%). No patient had evidence of diaphragm paralysis and there were no mesh infections. The 1-year hernia recurrence rate in these patients was 3.9%. A DRI can be done safely with minimal risk of intra- or post-operative complications. There was a low rate of herniation through the defect when repaired with permanent mesh. No patient developed a mesh infection despite concomitant Collis gastroplasty in 52% of patients, and there was no evidence of diaphragm paralysis on imaging studies. Further, the low rate ofhiatal hernia recurrence suggests efficacy of a DRI to reduce crural closure tension. These excellent outcomes should encourage use of a DRI in patients with a difficult hiatus during hernia repair.

Laparoscopic Treatment of Morgagni-Larrey Diaphragmatic Hernia with Reposition of the Transverse Colon in Patients with Cardiac Comorbidity. Clinical Observation

Morgagni-Larrey hernia is a rare form of diaphragmatic hernia (2-5% of cases) usually diagnosed in children; in adults, it is often detected in emergency cases or accidentally, during examinations or during surgery. The symptoms of the disease are non-specific, so the diagnosis is made using imaging methods (computed tomography is the gold standard). Currently, there is no single method of treating Morgagni-Larrey hernias. Closure of the defect is performed with or without the use of various mesh prostheses through the abdominal or thoracic route; open or minimally invasive access.
 The aim. To conduct a retrospective analysis of the treatment of adult patients with a Morgagni-Larrey diaphragmatic hernia, including those with cardiovascular comorbidity, with a comparison of symptoms, contents of the hernial sac, with the use of laparoscopic techniques and composite mesh prostheses.
 Materials and methods. The results of the treatment of three patients with a Morgagni-Larrey hernia in the period from 2020 to 2022 at the Shalimov National Institute of Surgery and Transplantation are shown. In two patients, the content of the hernial sac was a loop of the transverse colon, in one, the content of the hernial sac was a greater omentum. Taking into account the accompanying cardiovascular pathology, an interdisciplinary council consisting of a surgeon, anesthesiologist, and cardiologist recommended laparoscopic surgical intervention. Laparoscopic allogeneoplasty with composite prosthesis implantation was performed in three patients.
 Conclusions. The laparoscopic method of treating diaphragmatic hernias is safe and effective. The use of composite prostheses in combination with tension closure of the defect allows to reduce the risk of recurrence of the disease in the distant postoperative period.

Dog Ears in Wound Closure: Can They Be Minimized?

Conical deformities found at the apices of incisions after wound closure represent tissue redundancy, commonly known as "dog ears." The amount of tissue excess is related to the geometry of the incision, surrounding skin elasticity, and tension of closure. Experience with tissue handling shows that some dog ears do "settle" or resolve with time; such cases occur when local tissue has high skin elasticity, the dog ears are small in height, and tension on the line of closure is low. Dog ears that do not fall into this category can be troublesome to surgeon and patient alike as they can poorly impact aesthetic outcomes and lead to secondary revision procedures. Therefore, we present a pertinent review of the mechanisms behind dog-ear formation and the variety of surgical techniques used to minimize and correct their formation.

Role of Preoperative Skin Stretching in Single-Stage Wound Closure.

Background Mechanical skin stretching (SS) is now becoming one of the commonly sought after procedures for wound healing. This study was aimed to assess the efficacy of preoperative SS for the closure of large wounds and to evaluate various postoperative outcome parameters. Methodology An observational study was conducted from December 2017 to May 2019 where a sample size of 30 patients was included with inclusion criteria being wounds of ≥5 cm width that require surgical management, presence of sufficient healthy skin edge of the wound/scar (at least one) for the stretching procedure, and age between 18 and 70 years. SS devices used were the top closure tension relief system. Postoperatively, various parameters were recorded to evaluate outcomes and complications. Results Majority of wounds that is 16 (53.3%) were <50 cm 2 , 9 (30%) were between 50 and 75 cm 2 , and 5 (16.7%) were >75 cm 2 . The mean duration of stretch was 2.3 ± 0.82 weeks. For 30 wounds treated with staged cycles of wound closure, there was a significant difference between every two visit points, i.e., 10%. The mean patient-reported patient and observer scar assessment scale score was 3.5 ± 0.93. Twenty-five cases (83.3%) had uneventful postoperative recovery. Twenty-seven patients (90%) reported an improved aesthetic outcome. Fourteen patients (46.7%) reported some improvement in function. Conclusion The study concluded that the SS devices are the simple and effective method for the primary closure of large and challenging wounds and skin defects.

Trapezoid advancement flap to reconstruct small to medium sized tissue defects–A series of clinical applications

The choice between skin graft and local flap reconstruction depends upon the surgeon's experience and the facilities available. For skin cancers, our main objective is clear, oncologic clearance with preservation of function. For some patients, aesthetic outcome is often equally important. In our experience, majority of our trainees will often choose skin graft reconstruction as their primary choice of reconstruction due to the fact that there is a perceived idea that this is easier to perform than a local flap. However, for lower limb or head and neck reconstructions, skin graft may result in a significant contour defect which can potentially be avoided.We present a series of cases of an alternative flap, the trapezoid advancement, a very simple design that can be utilised in several areas of the body and technically very easily replicated. This technique allows for the advancement of tissue with a minimal tension closure as compared to other local flaps. Our results showed no flap loss and excellent cosmetic outcome.

How I Do It: Collis Gastroplasty

A key principle of hiatal hernia repair is mitigation of tension. While considerable emphasis is placed on the radial tension of the crural closure itself, of equal importance is assuring that axial tension on the esophagus is appropriately addressed. Because of this, esophageal lengthening procedures such as the transabdominal laparoscopic wedge Collis gastroplasty described here have been proposed. Such esophageal lengthening procedures allow for the creation of additional length of tubularized stomach to create a neo-esophagus that will allow for a tension free and appropriately sized fundoplication to be performed.

OV07 LAPAROSCOPIC HIATAL HERNIA MESH-SUTURE REPAIR

Abstract Aim “A new original laparoscopic operative technique was used to suture paraesophageal hernia (PEH) with the strips of mesh. Material and Methods The Mercilen (MercilenTM) mesh suture was used to close large hiatal hernia. The strips of mesh, instead of normal thread, were applied to close the gap between diaphragm’s crura in 12 patients with hernia defect more than 5 cm. Mesh suture were tighten as a simple laparoscopic intracorporeal knot. The surgical technique and surgical outcomes are presented. Results 12 patients underwent a laparoscopic PEH suturing with Mercilen strips of mesh. We recorded no recurrence or dysphagia at 6 and 12 months follow-up. Conclusions Mesh-sutured repairs of diaphragm’s hernia support the concepts of force distribution and resistance to suture pull through. The new original technique avoids using the sheet of mesh and enables to reduce the amount of dangerous complications connected with mesh and its fixation. Mesh-sutured closures of hiatal hernias seem to be safe and effective in tension closure of large hiatal defects. Further investigations are needed to evaluate the results. Using the mesh suture technique for the closure of large PEH, we protect the cruras from being cutting through. Besides, the mesh stripes and its knots produce tissue scarring around the esophagus making the suture line stronger.

Is Unilateral Local Flap Reconstruction Sufficient in Large Myelomeningocele Treatment?

Objective: Skin flaps are acceptable methods for surgical treatment of myelomeningocele defects in the neonatal period. Skin flaps (e.g., V-Y advancement, rotation or transposition flaps) are often preferred bilaterally for closure of myelomeningocele defects. This study evaluated the adequacy of an alternative unilateral flap method called “ice cream-cone flap” in repairing large myelomeningocele defects. Patients and Methods: Fifteen newborns who were operated with “ice cream cone flap” due to myelomeningocele defect were evaluated retrospectively. Surgical repair was carried out within 1–3 days of birth. The defect sizes were ranging 10 cm × 8 cm to 4 cm × 4 cm diameter with the mean diameter of 7.2 cm × 5.4 cm. This technique is mainly based on the planning of unilateral advancement flap that resembles the shape of the defect. The technique includes additional procedures such as anchoring of a deepithelialized skin tissue to provide redistribution of the wound closure tension to the lateral side of the flap, and transposition of a skin protrusion to shorten the peripheral border length of the wound. Results: Durable, stable soft-tissue coverage of the defect was obtained in all patients. No hematoma, seroma, infection, and flap necrosis were observed during the postoperative follow-up period. Two patients had partial wound dehiscence which was healed with secondary wound healing. Conclusion: “Ice cream-cone flap” technique is fast, reliable, and easily performed and has the advantage of shorter operative time, less blood loss with minimal wound closure tension.

“Flap-to-defect” concept for closure of circular skin defects: the ice cream cone flap

While sliding-type skin flaps such as advancement and rotation flaps are useful for closing circular skin defects that are too large to close primarily, these flaps are associated with some technical difficulties that must be overcome. In this study, we aimed to present our clinical experience using an alternative curvilinear advancement-transposition flap designed based upon a “flap-to-defect” concept. A retrospective review was conducted of patient charts and operative photographs of all “ice cream cone flaps” performed at the Department of Plastic and Reconstructive Surgery between May 2014 and November 2018. This method, for the repair of circular-shaped wounds, is intended to allow appropriate distribution of closure tension without necessitating changing the shape of the defect. Patient age, gender, defect size and region, postoperative complications, and esthetic/functional satisfaction were evaluated. The technique, based on the planning of a curvilinear advancement flap that mirrors the defect, was used for reconstruction of circular skin defects that involved various parts of the body. Information from 30 patients with defects ranging from 100 × 70 to 20 × 20 mm with a mean diameter of 30.3 × 20.8 mm were reviewed for the study. All flaps survived without wound infection, hematoma, or flap necrosis complications. During the follow-up period, acceptable esthetic results were achieved. This technique is a good alternative for the closure of small to moderate circular skin defects where adequate skin laxity is present. Level of evidence: Level IV, therapeutic study.

BIOMECHANICAL FACTORS IN RESIDUAL LIMB FORMATION AFTER AMPUTATION

The aim: To study the influence of biomechanical factors on the character of morphological disorders in the process of reparative regeneration at the end of the residual limb after amputation. Materials and methods: 10 series of experiments on 144 rabbits were conducted. We used myodesis with normal, insufficient and excessive muscle tension, their electrical stimulation, tight and leaky closure of the bone marrow canal. Terms of observation 1, 3, 6 months. The method of research – histological with the filling of vessels with inkgelatin mixture. Results: Dense closure of the meduallary cavity and uniform muscle tension during plasty in the first three series of experiments allow to obtain a cylindrical residual limb with preservation of the cortical diaphyseal plate, formation of the bone closing plate, normalization of intraosseous microcirculation, completion of the reparative process. In the majority of observations of the IV-X series there was a reparative regeneration disorder connected with the incorrect tension of muscles and the absence of normalization of intraosseous circulation, the reparative process was not observed to be complete, which led to the pathological reorganization of bone tissue with the formation of stumps of various shapes. Conclusions: Uneven muscle tension and lack of closure of the intramedually canal except for microcirculation disorders leads to increased periosteum bone formation, formation of periosteum cartilage exostases, clavate stumps, resorption and fractures of the cortical diaphyseal plate with curvature and stump axis disorders, formation of a conical stump.

Reducing the Cleft Nose Deformity in Bilateral Cleft Lip Repair.

Repair of a bilateral cleft lip and nose deformity remains a challenge. The nose remains the main persisting stigma for patients, deserving an equal amount of attention as the lip during the repair. We share 3 technical principles to help achieve the optimal nasolabial result and minimize cleft nose deformity after bilateral cleft lip repair. Firstly, cephalad rotation of C-flaps from the prolabium is used to define the nasolabial angle. Secondly, the nasal base and contour is set before the lip repair, as the vectors and tension of nasal repair differ from the vector and tension of the orbicularis oris muscle closure. Thirdly, different suspension and shaping stitches are used to define alar shape and position after lower lateral cartilage release, avoiding additional scars.

Standards and Trends in Lipoabdominoplasty.

Background:Lipoabdominoplasty has evolved over the last 6 decades through contributions from numerous luminaries in plastic and reconstructive surgery.Methods:The authors review historical perspective and provide a contemporary examination of trends in lipoabdominoplasty.Results:In 1967, Pitanguy popularized abdominoplasty (without liposuction) as a technique for augmenting ventral hernias repairs and subsequently for aesthetic improvement of the abdomen. After the introduction of suction assisted lipectomy by Illouz in 1983, abdominoplasty became a central tool in a diverse armamentarium of anterior and lateral abdominal wall contouring procedures. Liposuction was initially utilized with mini-abdominoplasty in order to improve contour. Subsequently, Matarasso advanced the safe combination of liposuction with full abdominoplasty. Additionally, he systematized the variety of cutaneous undermining, excision, and liposuction procedures utilized in abdominal contouring as indicated by the degree of skin laxity and musculofascial diastasis. Lockwood advocated high lateral tension closure of the superficial fascial system of the abdomen to improve the contour of the hips and flanks. Saldanha advanced selective undermining and anterior abdominal wall perforator preservation to minimize wound healing and seroma complications associated with lipoabdominoplasty procedures.Conclusion:In abdominal contour surgery, surgeons can rely on classic techniques and algorithms that have withstood the test of time while modifying their approaches with advances backed by compelling and rigorously obtained evidence.

Microfabricated Gaps Reveal the Effect of Geometrical Control in Wound Healing.

The geometry (size and shape) of gaps is a key determinant in controlling gap closure during wound healing. However, conventional methods for creating gaps result in un-defined geometries and poorly characterized conditions (cell death factors and cell debris), which can influence the gap closure process. To overcome these limitations, a novel method to create well-defined geometrical gaps is developed. First, smooth muscle cells (SMCs) are seeded in variously shaped micro-containers made out of hyaluronic acid hydrogels. Cell proliferation and cell tension induce fibrous collagen production by SMCs predominantly around the edges of the micro-containers. Upon removal of SMCs, the selectively deposited collagen results in micro-containers with cell-adhesive regions along the edges and walls. Fibroblasts are seeded in these micro-containers, and upon attaching and spreading, they naturally form gaps with different geometries. The rapid proliferation of fibroblasts from the edge results in filling and closure of the gaps. It is demonstrated that gap closure rate as well as closure mechanism is strongly influenced by geometrical features, which points to an important role for cellular tension and cell proliferation in gap closure.

Pressure reducing skin pie-crusting in extremity trauma: An in-vitro biomechanical study and human case series

Multiple small relaxing skin incisions oriented parallel to the longitudinal axis (so-called "pie-crusting") near traumatic lacerations or surgical incisions in edematous tissue beds have been utilized to achieve primary closure when edema or skin loss would otherwise have made this difficult. Our study hopes to demonstrate (1) biomechanical evidence that pie-crusting decreases wound closure tension and (2) provide a case series with data showing clinical results. This study is a biomechanical cadaveric study and retrospective small series cohort using 16 porcine limbs and 7 patients with 8 wounds in which pie-crusting was performed. An elliptical incision was made on the porcine limbs and the wound closure tension was measured with a hydraulic test machine before and after pie-crusting. The retrospective patient cohort had pie-crusting performed on traumatic wounds that were difficult to primarily close. The patient cohort was assessed by retrospective chart review examining wound dimensions before and after pie-crusting, and wound healing at final follow-up. The biomechanical data showed that pie-crusting the wound with both a single and double row of incisions significantly decreased the closing tension. A single row decreased wound tension by an average of 34%. Using an average of 3.5 parallel layers of pie-crusting at the time of definitive closure all wounds in the patient cohort closed and healed well with no complications at average follow-up (average 18 months). Pie-crusting may allow for easier wound closure and decrease the need for skin-grafting in edematous extremity wounds, with minimal patient morbidity.

Laparoscopic mesh-suture hiatal hernia repair

BACKGROUND: A new original laparoscopic operative technique was used to suture paraesophageal hernia (PEH) with the strips of mesh. METHODS: The Mercilen (MercilenTM) mesh suture was used to close large hiatal hernia. The strips of mesh, instead of normal thread, were applied to close the gap between diaphragm's crura in four patients with hernia defect more than 5 cm. Mesh suture were tighten as a simple laparoscopic intracorporeal knot. The surgical technique and surgical outcomes are presented. RESULTS: Four patients underwent a laparoscopic PEH suturing with Mercilen strips of mesh. We recorded no recurrence or dysphagia at 6 and 12 months follow-up. CONCLUSIONS: Mesh-sutured repairs of diaphragm's hernia support the concepts of force distribution and resistance to suture pull through. The new original technique avoids using the sheet of mesh and enables to reduce the amount of dangerous complications connected with mesh and its fixation. Mesh-sutured closures of hiatal hernias seem to be safe and effective in tension closure of large hiatal defects. Further investigations are needed to evaluate the results.

Percutaneous Fasciotomies versus Traditional Keystone Flap: Evaluating Tension in Complex Wound Closure.

The keystone flap is a popular reconstructive option for closure of cutaneous defects. Traditionally, this is a perforator-based fasciocutaneous advancement flap that uses both skin incision and fascial release. We propose a limited skin incision technique that utilizes percutaneous fasciotomies to accomplish wound closure. Fresh cadavers were used to compare closure techniques in traditional keystone flaps versus percutaneous fasciotomy technique. Each cadaver served as its own control; traditional keystone flaps were performed on the right side, experimental fasciotomy technique on the left. Bilateral large wound defects were created in 6 anatomical locations: anterior leg, lateral thigh, buttocks, lower back, upper back, and brachium. These defects could not be closed primarily, as defined by tension >25 Newtons or rupture of a 2-0 nylon suture. Twenty-four flaps were created. Keystone flaps were designed on the right side using a 1:1 ratio of defect size to flap width, incorporating both skin and fascial incisions. On the left, percutaneous fasciotomies were drawn using a mirror template and performed through two small access incisions. If wound closure could not be achieved by fasciotomy alone, additional incisional release was performed incrementally until closure was obtained. The tension of closure was measured using a PESOLA (10 N, 25 N) tensiometer (Chandelle, Switzerland), and the average of three recordings was used. Tension was measured at various stages of flap development including: keystone flap (posterior fascia, lateral fascia, V-Y skin closure) versus percutaneous fasciotomy (posterior fascia, lateral fascia, posterior skin). Statistical analysis was completed using Wilcoxon Signed Rank test to compare the two techniques. Lower tension closures were achieved through release of the posterior fascia in the traditional keystone flap compared to the percutaneous fasciotomy technique. These differences in tension were statistically significant (P < 0.001). Release of the lateral fascia in the keystone flap resulted in a similar decrease in tension (P < 0.01). The percentage drop in tension before and after each particular intervention was measured. No significant difference was found between these 2 groups. When compared with the traditional keystone flap, the percutaneous fasciotomy technique displayed higher tensions in closure. However, this technique showed the ability to close defects in certain locations of the body without excessive tension and should be considered as an option in soft-tissue reconstruction.

Quantifying tension in tension-free hiatal hernia repair: a new intra-operative technique.

A similar technique to measure crural closure tension has not been described before and with this method there is now a possibility to optimise this operation with objective measures, a hundred years after it was first described. The aims of this study were to develop a reliable method for measuring the tension of crural closure during hiatal hernia repair and to describe the tension characteristics of crural closure. 50 patients underwent crural tension measurement. Hiatal surface area (HSA) was measured intraoperatively and a Sauter FH 50 Universal Digital Force Gauge was used to measure the tension of crural closure during cruroplasty. Outcome measures included the mean tension of the crural closure and the presence of any muscle splitting during the cruroplasty. A combined total of 148 interrupted cruroplasty sutures were performed in all fifty patients. Each interrupted suture had three tension measurements recorded. The mean standard deviation amongst 148 sets of tension measurements was 0.27. Age, hiatal width and HSA were positively correlated with crural tension with r values of 0.44 (p = 0.0015), 0.81 (p < 0.0001) and 0.78 (p < 0.0001), respectively. Strength of association was low for age (r2 = 0.19) but moderate for hiatal width and HSA (r2 = 0.65 and 0.61, respectively). The presence of muscle splitting occurred at higher crural closure tension (5.3N vs. 1.62N, p < 0.0001). The lowest observed mean crural closure tension causing muscle splitting was 3.52N (IQR 3.93-6.77N). We have developed a technique for measuring the tension of crural closure during laparoscopic repair of hiatal hernia which is reproducible, quick, of low cost and requires only minimal additional equipment. Initial findings suggest that crural closure tension up to ~ 4N could be the permissible tension threshold for suture cruroplasty and higher tension often results in muscle splitting during cruroplasty.