Flap Creation Research Articles

The Vascular Anatomical Basis for a Well-Designed Reconstruction of the Ala Nasi by a Microsurgical Preauricular Flap Technique

Background: A microsurgical auricular flap represents a single-step technique for the reconstruction of full-thickness defects of the ala nasi. To achieve the best surgical outcomes, it is essential to have an exhaustive knowledge of the vascular network to improve the management of the surgical flap. This study aimed to provide an anatomical and surgical guide for a well-designed reconstruction of the ala nasi using a free preauricular flap. Methods: In this study, three fresh-frozen and two formalin-fixed human head specimens injected with red silicone rubber to enhance the arterial facial system were used. The reconstruction of the full-thickness defect of the ala nasi was performed using a microsurgical auricular flap technique, with the dimensions of the ala nasi and the preauricular flap duly noted. In addition, anatomical dissections were conducted, during which the positions and diameters of the main donor and recipient vessels were measured. Results: A presurgical evaluation was performed to define the flap design. A comparison of the shape and mean dimensions of the ala nasi defect (height 9.66 ± 1.40 mm; thickness 3.52 ± 0.53 mm) and the preauricular flap (height 8.50 ± 2.68 mm; thickness 3.92 ± 1.29 mm) indicated that this flap was an optimal option for the reconstruction of the ala nasi. The surgical procedure involved the full-thickness removal of the ala nasi, and the harvesting and insertion of the preauricular flap. The anatomical measurements demonstrated that the facial artery and veins were the optimal recipient vessels, with a diameter of >1 mm (2.08 ± 0.56 and 2.85 ± 0.74 mm), suitable for anastomosis with the superficial temporal artery and vein (1.86 ± 0.58 and 1.66 ± 0.15 mm). In addition, the postsurgical evaluations indicated a slight mean difference in the thickness (1.14 ± 0.65 mm) and height (1.68 ± 1.18 mm) between the ala nasi and helix and a satisfactory VAS score (7.9 ± 0.57). Conclusions: Our surgical and anatomical data provide compelling evidence in favour of free preauricular flap reconstructions of the ala nasi. This procedure allows for the correct choice of recipient vessels and the creation of a well-designed surgical flap.

Fowl Play Can Lead to Improved Surgical Skills: A Novel Simulation Model for Bladder Flap Creation, Colpotomy, and Vaginal Cuff Closure

Fowl Play Can Lead to Improved Surgical Skills: A Novel Simulation Model for Bladder Flap Creation, Colpotomy, and Vaginal Cuff Closure

Clinical safety and efficacy of elliptical thin-flap LASIK using a low-pulse energy femtosecond laser.

This study assessed the clinical safety and efficacy of elliptical thin-flap LASIK with a low-pulse energy femtosecond laser in 3 thickness subgroups (85, 90, and 100μm). A total of 80 patients who underwent bilateral LASIK surgery at Taiwan between April and September 2019 were retrospectively enrolled. Elliptical corneal flaps with wide temporal hinges and inverted-angled side cuts were created. Target flap thickness was calculated on the basis of residual stromal bed thickness and percent tissue altered. Before flap creation, an optical coherence tomography image for visualization of the precut flap position was obtained with the built-in camera. At postoperative month 1, the overall mean logMAR uncorrected distance visual acuity (UDVA) was - 0.04 ± 0.07 (20/18 Snellen), with 96% of eyes achieving UDVA of 20/20 or better. Postoperative mean manifest spherical equivalent was - 0.37 ± 0.42 D at 1 month. The visual and refractive outcomes in each of the 3 subgroups were similar. The achieved flap thicknesses were found to be highly predictable and consistent in the respective thickness subgroups. Optical coherence tomography-guided thin-flap LASIK performed with the low-pulse energy femtosecond laser was found to be safe with no intraoperative or postoperative complications.

Scar revision for persistent pain and activity limitation after exploratory laparotomy in infancy: A case series

AbstractExploratory laparotomy in neonates is typically performed via a transverse laparotomy incision. However, this incision may be complicated by poor cosmesis and scar contracture. In three patients, primary gastroenterologists identified significant scar contractures that resulted in pain and limitations with physical activity, necessitating surgical referrals. All patients required subsequent surgical revision of their scar, which involved creation of skin flaps, repair of abdominal wall hernias if present, and reapproximation of the subcutaneous tissue. We describe this phenomenon and the resultant need for surgical management to raise awareness of these late complications and suggest subcutaneous tissue reapproximation should be performed when possible during abdominal wall closure.

External Dacryocystorhinostomy Using Buccal Mucous Membrane Graft Following Resection of Lacrimal Sac: A Case Report

We report a case of a 10-year-old patient presented with recurring nasolacrimal duct obstruction post-lacrimal sac cyst extirpation in which CT scan revealed a solidlesion that was more depicted by contrast-enhancedimage. The initial surgery and flap creation had inadvertently led to a mucosal shortage, posing a challenge for the subsequent procedure, which aimed to create aDacryocystorhinostomy (DCR). In a challenging approach, a buccal mucous membrane graft was employed to address the lack of mucous membrane required for the DCR. Over the course of five years, there was no recurrence of the cyst, signifying the success of this innovative treatment method of using buccal mucous membrane graft for external DCR.

447. SAFETY AND FEASIBILITY OF DOUBLE FLAP RECONSTRUCTION (KAMIKAWA TECHNIQUE) AS ANTI-REFLUX MECHANISM AFTER GASTROESOPHAGEAL SURGERY

Abstract Background Gastroesophageal reflux is a common adverse effect after oncological surgery for tumors of the gastroesophageal junction. Some of the reasons are the radicality of the intervention as well as the placement of the anastomosis inside the thoracic cavity, where there is a constant negative pressure. In recent years, multiple methods of digestive tract reconstruction have been developed in order to re-establish this anti-reflux mechanism, such as the double flap reconstruction, first described by Kamikawa, consisting of the creation of a seromuscular flap covering the anastomosis. Methods We designed a retrospective observational and descriptive study including all patients who underwent esophagogastric surgery and Kamikawa doble-flap reconstruction technique from January 2019 to January 2024. The operation conditions, postoperative recovery, postoperative complications (both short and mid-long term), and follow-up data were collected and analyzed. Quantitative variables are described as median and range, and qualitative variables as absolute number and percentage. The IBM SPSS Statistics 22 software was used for the descriptive part. Results We included a total of 10 patients in our series. All of them underwent an esophagogastric resection followed by a doble-flap reconstruction technique. Thoracoscopy in prone position was the approach used in most of the patients. In these cases, the doble flap was performed using the posterior wall of the gastric remnant. Half of the patients had no postoperative complications and the other half, mild ones. Postoperative manometry and pHmetry were only performed in 4 patients due to technical difficulties. In all these cases the tests showed no alterations. Despite this, one patient reported reflux, which was controlled with PPIs. Conclusions The double flap reconstructive technique is a useful tool that can be applied to those patients undergoing an aggressive procedure in the gastroesophageal junction in order to restore its valvular mechanism. It can be performed through different approaches that best fit each surgical scenario. It does not bear greater postoperative complications than standard procedures and may prove to be a good option to improve the quality of life of selected patients.

Minimally invasive subperiosteal pocket technique for Osia 2 system- implantation without fixation.

The CochlearTM Osia® 2 is an active transcutaneous implant designed to treat patients with different types of hearing loss. Due to its size, implantation needs appropriate practice since the necessity of extended flap creation and bone work can be an issue in some cases. The goal of our study was to determine whether fixation of the OSI200 implant was necessary for the performance of patients with conductive or mild mixed hearing loss.The vibroacoustic performance of the Osia 2 system, with and without BI300 fixation, was evaluated through tests conducted on a head model. In addition, three patients underwent surgery using the modified minimally invasive subperiosteal pocket technique; the OSI200 implant was placed in a tight subperiosteal pocket without fixing it with the BI300 implant. To evaluate the audiological performance of the non-fixated Osia 2 system, we compared the preoperative unaided pure tone and suprathreshold testing with the Baha 5 sound processor and the non-fixated Osia 2 system aided thresholds.Initial results indicate that omitting fixation does not significantly impair the function of the Osia 2 system. The findings of the clinical assessment support the fact that the Osia 2 system performed better than the Baha 5 system on Softband, both in pure tone and suprathreshold tests.According to our results, we have found that utilizing the subperiosteal pocket method and implanting Osia 2 without BI300 fixation may be a viable option. This approach has shown promising results in terms of improving hearing ability with minimalization of surgery related complications.

Utility of ligamentum teres hepatis flap reinforcement to prevent postoperative pancreatic fistulas in robotic distal pancreatectomy

BackgroundPostoperative pancreatic fistula (POPF) is a significant contributor to morbidity and mortality after robotic distal pancreatectomy (RDP). Ligamentum teres hepatis (LTH) reinforcement of the pancreatic remnant may reduce the incidence of POPF. MethodsPatients ≥18 years old, who underwent RDP at the University of Massachusetts Memorial Medical Center from 01/01/2018-08/31/2022. Primary endpoint was POPF incidence. Secondary outcomes included peri- and postoperative variables. ResultsThirty-three patients underwent RDP, of which LTH reinforcement was used in 21 (64 ​%) cases. Six (18 ​%) patients developed a POPF. No association was identified between LTH flap reinforcement and POPF (OR 1.18, 95 ​% CI 0.18 to 7.85, p ​= ​0.87). There were no peri- or postoperative complications related to ligamentum teres flap creation. ConclusionsLTH reinforcement of the pancreatic remnant can be safely performed during RDP. Further studies are needed to assess the utility of this intervention to mitigate the risk of pancreatic fistula formation following RDP.

Scalp Flap Surgery - an Efficient Way to Save the Cranial Bone Flaps

Brain surgery often requires wide ecisions to ensure the radicality of the surgical intervention. In this contet, the role of the plastic surgeon becomes essential in the reconstructive stage where outstanding soft tissue defects following life-saving neurosurgical interventions often require creation of large local flaps. By effectively covering the defects with quality tissues, the rapid healing of patients is ensured, as well as obtaining stable results over time. This paper presents the salvage surgical approach in the case of a patient operated for the recurrence of a brain tumor, the rotation scalp flap being the optimal choice for this case.

Four-layer technique for tracheostomy scar treatment.

One important complication of the tracheostomy procedure is the depressed scar left after the tube is removed. A depressed tracheostomy scar can be aesthetically and functionally unacceptable. Tracheostomy scar treatment aims to fill lost soft tissue volume and correct tracheal skin tug. There are various techniques described to manage post-tracheostomy scars, including the use of autologous tissue or allogenic material and the creation of muscle flaps. In this article, the authors introduce a surgical method using four layers: the scar, the strap muscles, the platysma muscle, and the skin. This procedure has been used in two patients with depressed scar after prolonged tracheostomy placement. The tracheal tug was eliminated in each patient, and an imperceptible cutaneous scar remained. In each case, patient satisfaction was complete. The authors recommend this technique as a simple and effective method of closure for these troublesome tracheostomy scars.

Creation of a Corneal Flap for Laser In Situ Keratomileusis Using a Three-Dimensional Femtosecond Laser Cut: Clinical and Optical Coherence Tomography Features

Laser in situ keratomileusis (LASIK) is the most frequently used technique for the surgical correction of refractive errors on the cornea. It entails the creation of a superficial hinged corneal flap using a femtosecond laser, ablation of the underlying stromal bed using an excimer laser, and repositioning of the flap. A corneal flap with an angled side cut reduces the risk of flap dislocation and infiltration of epithelial cells and confers unique biomechanical properties to the cornea. A new laser software creating three-dimensional (3D) flaps using a custom angle side cut was retrospectively evaluated, comparing optical coherence tomography 3D (with intended 90° side cut) and 2D flaps (with tapered side cuts) as well as respective intra- and early postoperative complications. Four hundred consecutive eyes were included, two hundred for each group. In the 3D group, the mean edge angle was 92°, and the procedure was on average 5.2 s slower (p = 0). Non-visually significant flap folds were found in thirteen eyes of the 2D group and in seven eyes of the 3D group (p = 0.17). In conclusion, the creation of a LASIK flap using a 3D femtosecond laser cut, although slightly slower, was safe and effective. The side cut angle was predictable and accurate.

SMALL INCISION LENTICULE EXTRACTION – SMILE

SMALL INCISION LENTICULE EXTRACTION – SMILE

Mucosal flap creation in colorectal endoscopic submucosal dissection using a V-shaped incision.

Mucosal flap creation in colorectal endoscopic submucosal dissection using a V-shaped incision.

Continuous Fetal Cardiac Monitoring during Fetoscopic Myelomeningocele Repair and Relationship to Spectral Doppler Changes

Introduction: No evidence-based protocols exist for fetal cardiac monitoring during fetoscopic myelomeningocele (fMMC) repair and intraprocedural spectral Doppler data are limited. We determined the feasibility of continuous fetal echocardiography during fMMC repair and correlated Doppler changes with qualitative fetal cardiac function during each phase of fMMC repair. Methods: Patients undergoing fMMC repair had continuous fetal echocardiography interpreted in real-time by pediatric cardiology. Fetal data included fetal heart rate (FHR), qualitative cardiac function, mitral and tricuspid valve inflow waveforms, and umbilical artery (UA), umbilical vein (UV), ductus arteriosus (DA), and ductus venosus (DV) Dopplers. Results: UA abnormalities were noted in 14/25 patients, UV abnormalities were observed in 2 patients, and DV and DA abnormalities were each noted in 4 patients. Qualitative cardiac function was normal for all patients with the exception of one with isolated left ventricular dysfunction during myofascial flap creation, concurrent with an abnormal UA flow pattern. All abnormalities resolved by the first postoperative day. Conclusions: Continuous fetal echocardiography was feasible during all fMMC repairs. Spectral Doppler changes in the UA were common during fMMC procedures but qualitative cardiac dysfunction was rare. Abnormalities in the UV, DV, and DA Dopplers, FHR, and cardiac function were less common findings.

Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review.

Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally advanced rectal cancer (LARC) on presentation. For LARC invading into other structures (i.e. T4b), multivisceral resection (MVR) and/or pelvic exenteration (PE) remains the only potential curative surgical treatment. MVR and/or PE is a major and complex surgery with high post-operative morbidity. Minimally invasive surgery (MIS) has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies, but there is little evidence on its use in MVR, especially so for robotic MVR. To assess the feasibility and safety of minimally invasive MVR (miMVR), and compare post-operative outcomes between robotic and laparoscopic MVR. This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023. Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR, or stage 4 disease with resectable systemic metastases. Patients who underwent curative MVR for locally recurrent rectal cancer, or metachronous rectal cancer were also included. Exclusion criteria were patients with systemic metastases with non-resectable disease. All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery. Complex surgery was defined based on technical difficulty of surgery (i.e. total PE, bladder-sparing prostatectomy, pelvic lymph node dissection or need for flap creation). Our primary outcomes were the margin status, and complication rates. Categorical values were described as percentages and analysed by the chi-square test. Continuous variables were expressed as median (range) and analysed by Mann-Whitney U test. Cumulative overall survival (OS) and recurrence-free survival (RFS) were analysed using Kaplan-Meier estimates with life table analysis. Log-rank test was performed to determine statistical significance between cumulative estimates. Statistical significance was defined as P < 0.05. A total of 46 patients were included in this study [open MVR (oMVR): 12 (26.1%), miMVR: 36 (73.9%)]. Patients' American Society of Anesthesiologists score, body mass index and co-morbidities were comparable between oMVR and miMVR. There is an increasing trend towards robotic MVR from 2015 to 2023. MiMVR was associated with lower estimated blood loss (EBL) (median 450 vs 1200 mL, P = 0.008), major morbidity (14.7% vs 50.0%, P = 0.014), post-operative intra-abdominal collections (11.8% vs 50.0%, P = 0.006), post-operative ileus (32.4% vs 66.7%, P = 0.04) and surgical site infection (11.8% vs 50.0%, P = 0.006) compared with oMVR. Length of stay was also shorter for miMVR compared with oMVR (median 10 vs 30 d, P = 0.001). Oncological outcomes-R0 resection, recurrence, OS and RFS were comparable between miMVR and oMVR. There was no 30-d mortality. More patients underwent robotic compared with laparoscopic MVR for complex cases (robotic 57.1% vs laparoscopic 7.7%, P = 0.004). The operating time was longer for robotic compared with laparoscopic MVR [robotic: 602 (400-900) min, laparoscopic: Median 455 (275-675) min, P < 0.001]. Incidence of R0 resection was similar (laparoscopic: 84.6% vs robotic: 76.2%, P = 0.555). Overall complication rates, major morbidity rates and 30-d readmission rates were similar between laparoscopic and robotic MVR. Interestingly, 3-year OS (robotic 83.1% vs 58.6%, P = 0.008) and RFS (robotic 72.9% vs 34.3%, P = 0.002) was superior for robotic compared with laparoscopic MVR. MiMVR had lower post-operative complications compared to oMVR. Robotic MVR was also safe, with acceptable post-operative complication rates. Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

Comparison of the use of internal limiting membrane flaps versus conventional ILM peeling on post-operative anatomical and visual outcomes in large macular holes

BackgroundIdiopathic full-thickness macular hole (iFTMH) closure rates following conventional vitrectomy, gas tamponade and internal limiting membrane (ILM) peeling decrease when the minimum linear diameter (MLD) ≥ 500 microns. ILM flap creation has been proposed to improve closure in larger holes. This study evaluated the anatomical and functional impact of ILM flap introduction to routine practice in iFTMH ≥500 microns.MethodsRetrospective, interventional analysis of prospectively collected data of 191 eyes from consecutive surgeries for primary iFTMH ≥500 microns performed by two surgeons between June 2018 and June 2022, during which both surgeons replaced ILM peeling with ILM flap creation. Post-operative best-corrected visual acuity (BCVA) and anatomical closure were compared between Group 1 (ILM peel) and Group 2 (ILM flap) in an intention-to-treat analysis.ResultsRates of iFTMH closure were greater in the ILM flap group (77/80; 96.3%) than the ILM peel group (94/110; 85.5%) (OR = 4.37, 95% CI = 1.23–15.55, p = 0.023). A non-significant increase in post-operative BCVA improvement was observed in the ILM flap group (p = 0.084). There was no statistically significant difference in final BCVA (p = 0.83). Multivariate logistic regression found only MLD (OR = 0.993, 95% CI = 0.989–0.997, p = 0.001) and ILM flap group (OR = 5.795, 95% CI = 1.313–25.570, p = 0.020) predicted primary closure.ConclusionILM flap creation improves closure rates in larger holes and should be considered routinely in iFTMH ≥500 microns. Whether ILM flaps affect post-operative visual function remains uncertain.

Adipofascial Perforator Flaps for Peripheral Nerve Resurfacing after External Neurolysis.

Background: External neurolysis is an important approach to treating symptomatic peripheral nerve entrapment. In cases of recurrent neurolysis or particularly extensive neurolysis, a paucity of overlying soft tissue for closure over the freshly liberated nerve presents a challenge to long-term surgical success as primary closure of this tissue may predispose the patient to recalcitrant epineural scarring. We report the intermediate term outcomes of the use of adipofascial perforator flaps as a means of vascularised tissue resurfacing of nerves in these difficult scenarios. Methods: We retrospectively reviewed patients undergoing external neurolysis for painful peripheral nerve lesions who subsequently had soft tissue reconstruction with local adipofascial flaps. Data with regard to age, gender, limb involved, duration of symptoms, number of prior surgeries, operative time, type of flap, vascular basis of flap, duration of follow-up, visual analogue pain score, monofilament sensory testing and complications were collected. Results: We included six patients (four women) with a minimum follow-up period of 17 months (range: 17-25 months). Age ranged from 39 to 60 years of age. Four cases involved the upper extremity and two the lower extremity. Symptoms had been present between 1 and 10 years. All operations utilised a local adipofascial flap perfused by a named perforating vessel emanating from an adjacent axial vessel. Operative time for flap creation and inset was 74 minutes, on average. There was one minor complication owing to superficial wound dehiscence. All patients reported substantial pain relief (≥five-point reduction on visual analogue scale; scores 0-3 at last follow-up) and objective sensory testing demonstrated improvement. Conclusions: Our report pays particular attention to surgical technique that is applicable to both upper and lower extremities in addition to intermediate term safety and pain outcomes. Level of Evidence: Level IV (Therapeutic).

Squamous cell carcinoma of lip: Clinical feature analysis and suggestion of reconstruction algorithm.

Reconstruction of lips after squamous cell carcinoma (SCC) removal should restore functional and aesthetic roles; however, it remains a challenge. In this study we describe the clinical features of lip SCC and suggest a reconstruction algorithm. We retrospectively analyzed 34 patients with lip SCC who underwent reconstruction after Mohs micrographic surgery between January 2006 and March 2022. The mean age of the patients was 70.2 years. Seven tumors were on the upper lip and 27 tumors were on the lower lip. Twenty-five defects were located on the mucosal lip, eight defects involved both the mucosal and cutaneous lips, and one defect was confined to the cutaneous lip. Eighteen defects were smaller than 50% of the total lip size, and 16 were larger than 50%. Primary closure was mostly performed for defects smaller than 50% of the lip size (9/18 cases), and local flap, according to the location and size of the defects, was performed for larger defects. Thirteen patients experienced postoperative complications but improved within 1 year after surgery, except for one patient. We suggest a reconstruction algorithm with a 50% cut-off value. Defects smaller than 50% of the lip size could be reconstructed by primary closure. Even larger defects could be reconstructed by creation of a local flap from the remaining adjacent tissue with minimal postoperative complications.

Angiosome Origins and Concept

An angiosome is a composite block of tissue fed by a primary source artery. The term angiosome is derived from the Greek words angeion, which means channel, and somite, which means segment or sector of the body derived from soma, body. Angiosomes can be further differentiated into individual skin perforators or into matching venosomes (venous regions) and arteriosomes (arterial territories). The concept of angiosomes plays a pivotal role in surgical procedures involving tissue transplantation and composite flap formation. The secure anatomic borders defined by angiosomes enable the precise identification and isolation of tissues at various layers, facilitating the transplantation of individual components or the creation of composite flaps.

Hydrodissection to create conjunctival flaps in dogs with corneal ulcers.

Hydrodissection is a liquid injection technique that is rarely used in animal ophthalmic procedures. The use of this technique in the creation of conjunctival flaps for the treatment of corneal ulcers in dogs can improve the outcome, task, and comfort for patients. This study aimed to evaluate the use of hydrodissection in the creation of conjunctival flaps in dogs with corneal ulcers. This study focused on a surgical procedure for creating conjunctival flaps in the eyes of 17 dogs with deep corneal ulcers. We divided the patients into two groups: Hydrodissection was performed in the first group (G1) and conventional divulsion without hydrodissection in the second group (G2). In G1, the conjunctival flap was created by subconjunctival injection of 1 mL of 0.9% sodium chloride, followed by flap construction. The flap was constructed through conventional divulsion using iris scissors in the G2. The operative time, degree of bleeding, and ease of conjunctival divulsion were evaluated during the procedure. Blepharospasm, hyperemia, edema, and scarring of the conjunctiva were evaluated during the post-operative period. Post-operative complications, notably suture dehiscence, were recorded in each group. Hydrodissection is an easy-to-perform maneuver that optimizes the construction of conjunctival flaps. There were no statistical differences in the parameters used to evaluate the trans- and post-operative period between the groups. The volume of sodium chloride administered in the conjunctiva ranged from 0.5 mL to 1 mL in G1. Dehiscence of the flap sutures was observed in four patients (two in G1 and two in G2), with no significant difference between the groups. Hydrodissection facilitates the construction of conjunctival flaps in dogs with corneal ulcers, affording greater comfort to patients and proving to be an excellent option for ophthalmologists.