Dorsal Graft Research Articles

Current Trends in the Use of Buccal Grafts During Urethroplasty Among Society of Genitourinary Reconstructive Surgeons

ObjectivesTo analyze current standards in urethroplasty by urologists employing buccal mucosal grafts (BMG) for treating urethral stricture disease (USD). MethodsAn IRB-approved online survey was distributed to members of the Society of Genitourinary Reconstructive Surgeons (GURS) between July and October 2022 to assess BMG utilization in urethroplasty. Questions covered surgeon experience, graft harvest site, graft length, surgical technique, and perceived success rates. ResultsOf 350 invited GURS members, 134 responded (38%). 69% were GURS fellowship-trained, performing 10-30 urethroplasties annually. 95% harvested their own grafts, with 99% preferring buccal mucosa as the primary site. Buccal mucosa was favored over fasciocutaneous flap for penile urethroplasty, regardless of circumcision status (95% with, 84% without). For bulbar urethroplasty with BMG, dorsal graft placement was favored (66%) over ventral (34%). Most surgeons (90%) preferred multiple BMGs over combined graft/flap for panurethral strictures. When harvesting long grafts, 56% preferred using both cheeks. Anastomotic urethroplasty was preferred over buccal graft urethroplasty for short bulbomembranous stenosis post-radiotherapy (63% vs. 37%). Surgeons reported a success rate of 80-90% (53%). ConclusionsThe expanded scope of reconstructive urology has led to increased use of BMG in diverse urethral reconstructions. Buccal grafts are now preferred for penile, bulbar, and panurethral strictures, demonstrating high perceived success rates in the reconstructive community.

Two Cases of Unilateral Osteotomies for Traumatic Severely Deviated Noses

A severely deviated nose accompanied with trauma is difficult to correct, but osteotomy, a common surgical technique, can correct such deviation. This study aims to evaluate the usefulness of unilateral osteotomy, a technique for correcting a severely deviated nose driven by trauma. Two patients, both with deviated nose caused by trauma but one with a C-shaped nose and another with a reverse C-shaped nose, underwent surgery. Cartilage and bone humps were removed by a knife and a rubin osteotome, respectively. Unilateral osteotomy was performed on the convex area to correct the crooked nose and camouflage dorsal graft was used to treat the lowered dorsum. No postoperative complications were reported during the follow-up periods. Both patients were satisfied with the outcomes. This paper presents successful cases of unilateral osteotomy and suggests this treatment as an effective way of correcting deviated nose caused by trauma.

Novel Z Technique to Overcome Warping of Costal Cartilage.

Rhinoplasty has become one of the most popular operations in recent years and autologous costal cartilage is usually chosen as the graft material in dorsal augmentation. However, the warping tendency of rib cartilage may jeopardize the aesthetic results of rhinoplasty.1,2 Many methods have been proposed to address this problem. The accordion technique is based on the theory that protein polysaccharides—the biomechanical infrastructure of all cartilage—produce interlocking stresses (intrinsic forces) that lead to warping.3 In this procedure, to break the recoil mechanism responsible for warping, transverse cuts were made through 75% of the graft width every 1 to 2 mm along the entire graft length, alternating between its two sides.4 This method has been widely used for dorsal augmentation but has not eliminated the problem; mild warping is still reported. Our group theorizes that this technique eliminates the graft’s intrinsic warping forces but increases the graft’s pliability and therefore the likelihood of distortion when an external force is applied. When grafts are implanted for dorsal augmentation, the following conditions will occur. First, although the costal cartilage is carved to match the shape of the nasal bone, a small space will exist between graft and bone, allowing a slight displacement of grafts. Second, the length of the dorsal graft (~4 cm) increases the rate of external forces, including gravity, inspiratory and expiratory forces, and asymmetric facial muscle activity. Third, the caudal end of the graft is fixed firmly to the nasal tip cartilage framework, but the cephalic end is only loosely placed under the periosteum; this makes the graft susceptible to deformation when it undergoes external forces. Therefore, the graft’s pliability magnifies the effect of external forces and contributes to the warp of dorsal graft. A good prefabricated technique to decrease the risk of warping should not only eliminate intrinsic warping forces but also decrease the deforming effect of external forces. To achieve this, the authors combined the principles of the oblique split technique and accordion technique to create a new Z technique for nose dorsal augmentation. Different from the accordion technique, oblique cuts (45 degrees to the longitudinal axis) were made along the graft length every 4 mm, with alternate short (5.5 mm) and long incisions (10.0 mm) made on the two sides (Fig. 1). The warping angles and biomechanical test of the Z technique were compared with the accordion technique in an in vitro study. The results indicated that by changing the cutting direction and the angle of the incision to the longitudinal axis, not only were the intrinsic warping forces eliminated, but also every part of the operated graft was antagonistic to each other so that the pliability and effects of external forces were decreased.Fig. 1.: Accordion technique and Z technique. The grafts were incised along the length of the graft; the spacing between two adjacent cuts is about 4 mm in both techniques. The cuts are 90 degrees to the long axis in the accordion technique and 45 degrees to the long axis in the Z technique.Although further in vivo studies should be performed, the novel Z technique is a simple and reliable procedure to overcome the problem of costal cartilage warping after dorsal augmentation in rhinoplasty. ACKNOWLEDGMENTS This work was supported by the National Natural Science Foundation of China (grant 82072182) and the Shaanxi Province Key R&D Program Project, China (grant 2020SF-179). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article. DISCLOSURE The authors declare that they have no competing interests.

Improvement of Nasal Dorsal Onlay Graft Appearance after Augmentation Rhinoplasty with Costal Cartilage for Thin-Skinned Patients.

The camouflage of the nasal dorsum is very important for thin-skinned patients. In this study, the authors presented an improved method for these patients and evaluated the safety and efficacy of this method in augmentation rhinoplasty. Fifty-two thin-skinned nose Chinese patients, ranging in age from 18 to 42 years, who underwent open augmentation rhinoplasty with modified perichondrium on dorsal onlay graft were included in the study. Among these patients, 24 of them were primary cases, and the other cases were secondary. The Rhinoplasty Outcomes Evaluation (ROE) scale and Visual aid scoring (VAS) questionnaire were used to evaluate aesthetic outcomes. During the long-term follow-up (ranging from 6 to 20 months), the ROE scores of each item before and after surgery were statistically significant in our study. The total scores of the preoperative and postoperative ROE scale of the study were 9.77 ± 3.18 and 20.65 ± 1.88, respectively, which indicated reasonably high satisfaction. According to the VAS questionnaire, patients' own evaluations of the nasal dorsal improvement rendered a high satisfaction rate. One case of fat liquefaction at the donor site and two cases of warping occurred and no other major complications were encountered. Covering the two edges of the graft with perichondrium on the onlay dorsal graft seems a convenient and effective method for thin-skinned augmentation rhinoplasty, which was the best choice for camouflage of the nasal dorsum in our department. IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Treatment of Meatal Strictures by Dorsal Inlay Oral Mucosa Graft Urethroplasty: A Single-Center Experience.

Background: To report on the use of oral mucosa graft urethroplasty for meatal strictures using the dorsal inlay technique. Methods: Patients who underwent a single-stage dorsal inlay oral mucosal graft urethroplasty between January 2000 and May 2021 were included in this study. A follow-up of a minimum of 12 months was necessary for inclusion. Exclusion criteria were stricture extension into the penile urethra, concomitant stricture at another location, flap urethroplasty for a meatal stricture, dorsal inlay urethroplasty with another type of graft, ventral onlay graft urethroplasty or staged urethroplasty. Recurrence was defined by the inability to pass a 14F metal sound through the reconstructed meatus irrespective of patients’ complaints. Results: Our study cohort included 40 patients. Buccal mucosal graft (BMG) urethroplasty was used in 25 patients and 15 patients were treated with the aid of lingual mucosal graft (LMG). The median follow-up was 85 (IQR: 69–110) months. Seven (17.5%) patients suffered a stricture recurrence of which four (10%) needed re-intervention. The median 5-y recurrent free survival (RFS) for the entire cohort was 85 (±6)%. The median 5-y RFS was 96 (±4)% versus 65 (±13)% for respectively BMG and LMG (p = 0.03). Post-operative complications were identified in 11 (27.5%) patients with only one (2.5%) patient who had a grade 3a complication. Conclusions: Dorsal inlay oral mucosa graft urethroplasty is a safe and feasible technique for selected patients with meatal stenosis.

PD22-06 A MODIFIED APPROACH TO MEDIUM-LENGTH OBLITERATIVE BULBAR STRICTURES: TECHNIQUE AND OUTCOMES OF THE MUCOMUCOSAL ANASTOMOTIC NON-TRANSECTING AUGMENTATION (MANTA) URETHROPLASTY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II (PD22)1 Sep 2021PD22-06 A MODIFIED APPROACH TO MEDIUM-LENGTH OBLITERATIVE BULBAR STRICTURES: TECHNIQUE AND OUTCOMES OF THE MUCOMUCOSAL ANASTOMOTIC NON-TRANSECTING AUGMENTATION (MANTA) URETHROPLASTY Phillip Marks, Roland Dahlem, Maryam Khonsari, Lennart Kühnke, Frederik König, Margit Fisch, and Malte W. Vetterlein Phillip MarksPhillip Marks More articles by this author , Roland DahlemRoland Dahlem More articles by this author , Maryam KhonsariMaryam Khonsari More articles by this author , Lennart KühnkeLennart Kühnke More articles by this author , Frederik KönigFrederik König More articles by this author , Margit FischMargit Fisch More articles by this author , and Malte W. VetterleinMalte W. Vetterlein More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002011.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: For short and obliterative bulbar strictures, non-transecting excision and primary anastomosis (EPA) has come of age to avoid disrupting spongiosal blood flow. Longer obliterative strictures may be treated by a combined "double" ventral + dorsal graft (Palminteri et al. 2008) or an augmented anastomotic approach, which was recently refined by a non-transecting technique combining EPA and a dorsal graft (Welk et al. 2012; Bugeja et al. 2016). We here present the initial experience with our ventral modification of this technique, the mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty. METHODS: We included patients with an obliterative bulbar segment (≤2 cm) and mild to moderate spongiofibrosis undergoing MANTA between 2016-2019. The stricture is approached by ventral stricturotomy to avoid extensive urethral dissection and mobilization from the corpora cavernosa. Dorsally, the scar is superficially excised and the spongiosum is left intact. Dorsal mucomucosal anastomosis (excluding sponge tissue) is performed, which is complemented by a ventral onlay buccal mucosal graft. Perioperative characteristics were prospectively collected including uroflowmetry data and validated PROMs (6-item LUTS score of the USS PROM). We evaluated the postoperative improvement of objective (uroflowmetry at three weeks postoperatively) and functional follow-up, which incorporated patient-reported parameters (LUTS score) and functional success, whereas recurrence was defined as the symptomatic need of any re-intervention. RESULTS: Median age in 54 men undergoing MANTA was 51 yr, 83% and 26% had a history of ≥1 urethrotomy and urethroplasty, respectively. Stricture location was bulbar in 70% and penobulbar in 30%. Median operative time and graft length was 55 min and 4 cm, respectively. In 35 patients with measurable uroflowmetry data, median Qmax significantly improved (7.7 ml/s preoperatively to 31 ml/s three weeks postoperatively; p<0.001). Cross-sectional functional follow-up was performed at a median of 40 mo (range 5-57) postoperatively and was available in 50/54 patients (93% response rate). Preoperative median 6-item LUTS score was 12 (IQR 8–14) and improved significantly after surgery to a postoperative median of 1 (IQR 0-3; p<0.001). Overall success was 93% with 4/54 patients suffering from functional stricture recurrence and the need of a re-intervention. CONCLUSIONS: MANTA urethroplasty using a ventral onlay provides excellent mid-term results in patients with bulbar strictures with an obliterative segment ≤2 cm and adds to the surgical armamentarium of non-transecting techniques by minimizing extensive mobilization. Source of Funding: n/a © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e382-e382 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Phillip Marks More articles by this author Roland Dahlem More articles by this author Maryam Khonsari More articles by this author Lennart Kühnke More articles by this author Frederik König More articles by this author Margit Fisch More articles by this author Malte W. Vetterlein More articles by this author Expand All Advertisement Loading ...

Treatment of panurethral strictures using one side dissection dorsal onlay buccal mucosal graft urethroplasty

The management of panurethral stricture was still challenging and controversial. We presented a case of pan urethral strictures management by using a one-sided dissection of dorsal onlay buccal mucosal graft (BMG) urethroplasty (Kulkarni technique). A 53-years old man admitted with panurethral stricture who had previously undergone several procedures. Bipolar micturition cystourethrography procedure revealed 17 cm stricture length. One-sided dissection dorsal onlay buccal mucosal graft urethroplasty was performed. No drain was placed. The Foley catheter was removed four weeks after surgery, and the results of the micturition were favourable. No fistulae were found at a straight erection and meatus at a normal position. The postoperative flow rate (Qmax) was 24.9 ml/second. As a conclusion Kulkarni technique urethroplasty gained good outcome for panurethral stricture in our case.

Skin Necrosis Following Rhinoplasty: A Review and Proposed Strategy on Identifying High-Risk Patients.

Vascular compromise leading to cutaneous loss following surgical rhinoplasty is a devastating complication. The objective of this review is to identify all reported cases in literature published in English and summarize the current evidence to identify the patients at risk of this complication following surgery. A comprehensive literature review using Medline and Embase databases was performed to capture all reported cases of cutaneous vascular compromise following rhinoplasty from database inception through September 2020. Nonsurgical rhinoplasty cases were excluded. We identified eight studies that featured vascular cutaneous compromise following surgical rhinoplasty. A total of 18 patients were included in the analysis. The majority of the patients were females with a mean age of 30.9. Risk factors included smoking in 23.5% patients and revision setting. Extensive tip thinning, tight splinting and taping with dorsal onlay grafting, or combining extended alar base excision with revision open rhinoplasty were among surgical techniques associated with vascular compromise. The most commonly affected aesthetic nasal subunit in our review was the dorsum followed by the nasal tip. Conservative management primarily was utilized in 72.2% of patients, allowing the defect to heal by secondary intention. Studies reporting on cutaneous vascular compromise following surgical rhinoplasty are of low level of evidence. This review is the largest summary reporting on this complication to date, aiming to caution surgeons about associated techniques and management options. We also share an expert opinion on preoperative assessment of nasal skin to guide surgeons to potentially avoid rhinoplasty surgery in this subset of patients.

One-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-Analysis.

Performing 1-stage urethroplasty in patients with urethral strictures caused by lichen sclerosus (LS) is hotly debated among reconstructive urologists due to conflicting reports of success. Therefore, the objective of this study was to determine the pooled incidence of stricture recurrence following 1-stage buccal mucosal graft (BMG) urethroplasty in patients with LS, to determine the impact of surgical technique on recurrence and to compare recurrence risk between patients with and without LS after 1-stage repairs. A systematic review was conducted in accordance with PRISMA criteria. The primary outcome was pooled incidence of recurrence, which was calculated using a Der-Simonian-Laird binary random effects model with a Freeman-Tukey arcsine transformation. A total of 21 studies were included, of which 15 provided data for comparative analyses. Pooled data from 625 LS patients revealed a stricture recurrence rate of 10% (95% CI 6-14). Among studies with longer followup (≥24 months), this increased to 18%. Among patients with penile urethral involvement, studies utilizing a penile skin incision had significantly higher pooled recurrence rates than those utilizing penile invagination (p=0.004). Across all studies, there was no evidence to suggest a difference in pooled recurrence rate between patients with and without LS (p=0.36). However, across only long-term studies, recurrence risk was significantly higher for patients with LS (OR 1.83, p=0.05). One-stage BMG urethroplasty is likely a viable surgical option for patients with LS-related strictures; however, high-quality data are limited. Future multi-institutional, long-term prospective studies are needed to assess durability of 1-stage repair.

Dorsal vaginal graft urethroplasty in female urethral stricture: a contemporary series

BackgroundBladder outlet obstruction (BOO) is an uncommon entity in women. The incidence is only 2.7–8% of women referred for voiding symptoms. It is common to treat female urethral strictures by repeated urethral dilatations with subsequent self-intermittent catheterisation, which often leads to stricture recurrence. We aim to review the technique and outcomes of Dorsal vaginal graft Urethroplasty (DVGU) to manage urethral strictures in females.MethodsThis study is a retrospective chart review of 24 women with urethral stricture who underwent dorsal vaginal graft urethroplasty by a single surgeon. Patients were selected based on history, physical examination, uroflowmetry, urethral calibration, urethroscopy and voiding cystourethrography. We compared the pre- and postoperative values of variables such as the peak flow (Qmax), post-void residual (PVR) and self-reporting satisfaction score.ResultsMean (range) age of the patients was 46.54 (38–55) years. The mean PVR was 6.35 ml/s and 148.12 ml/s, respectively. The mean Qmax before and after surgery was 6.35–25.12 ml/s, respectively (p < 0.05). The mean PVR decreased from 148.12 ml (preoperative) to 41.67 ml (postoperative) (p < 0.05). Before and after surgery, the mean calibration size was 12.76 F and 24.50 F, respectively (p < 0.05). Self-reported satisfaction score (Patient Global impression of improvement) showed that five (5) patients scored 1 (very much better), sixteen (16) patients scored 2 (much better) and three (3) patients scored 3 (a little better). Three women (12.5%) had stricture recurrence. Two of them got stabilised with initial soft dilatation, and the third women required continued self-catheterisation. Overall, the success rate was 87.5% with a mean (range) follow-up of 22.62 (12–36) months.ConclusionDorsal onlay vaginal graft urethroplasty is a simple, safe and practical approach to treat female urethral stricture with a reasonable success rate. It can be considered as a first-line option for definitive repair.

Optimization of the Soft Tissue Envelope of the Nose in Rhinoplasty Utilizing Fat Transfer Combined with Platelet-Rich Fibrin.

A thin or damaged skin soft tissue envelope may cause concerns in primary and secondary rhinoplasty. During postoperative healing, unpredictable scarring and contraction may occur and lead to significant aesthetic and trophic sequelae. Besides a meticulous surgical technique, there are no reliable techniques to prevent long-term skin damage and shrinkage. Fat transfer with addition of platelet-rich fibrin (PRF) harbors the possibility of local soft tissue regeneration and skin rejuvenation through growth factors and mesenchymal stem cells. It may also facilitate the creation of a thin fat layer on the dorsum to prevent shrink-wrap forces and conceal small irregularities. The goal is to provide evidence for the feasibility, durability, and beneficial effect of diced macrofat transfer bonded with PRF on the nasal dorsum. We present the technique of fat transfer conjugated with PRF as a nasal dorsal graft. Clinical endpoints were the prevention of trophic disturbances and atrophy at a 1-year postoperative follow-up. We present the skin mobility test as a clinical indicator of a healthy soft tissue envelope. The presented case series consists of 107 rhinoplasties. Fat was harvested in the umbilical or costal region. PRF was created by centrifugation of autologous whole blood samples. Macrofat was diced, cleaned, and bonded with PRF. The compound transplants were transferred to the nasal dorsum. There were no perioperative complications or wound-healing issues. Mean follow-up was 14 months. Clinical inspection showed good skin quality and no signs of shrinkage, marked scarring, or color changes with positive skin mobility test in all patients. Survival of fat was confirmed by ultrasonography and magnetic resonance imaging. Diced macrofat transfer in conjunction with PRF to the nasal dorsum is a feasible and safe method. A beneficial effect on the soft tissue envelope is demonstrated as well as the prevention of shrink-wrap forces.

Management of men with ultra-short penile urethral stricture using augmented anastomotic penile skin flap urethroplasty; a retrospective analysis

BackgroundThe management of short anterior urethral stricture is challenging. Our study aims to evaluate the outcome of augmented anastomotic urethroplasty (AAU) for the management of men with ultra-short penile urethral stricture, and to compare it with the dorsal onlay buccal mucosa graft.MethodsDatabases of two tertiary referral centres were retrospectively reviewed to retrieve data of men with ultra-short penile urethral stricture who underwent urethroplasty from 2013 to 2020. Patients who underwent AAU with ventral onlay pedicled skin flap were considered the study group, while patients treated with the dorsal onlay graft augmentation were included as controls. Surgical outcomes included urethral patency, improvement in the maximum flow rate (Qmax), change in sexual satisfaction, and any reported complications.ResultsThirty-four patients (and 30 controls) with a median age of 26–27 years were included in the study. The maximum flow rate improved significantly in both groups compared to the preoperative value (p < 0.001). The success rate was 88% in the study group compared to 76.7% in the control group. There was no statistically significant difference in the frequency of postoperative penile curvature nor the ventral sacculation between the two groups (p = 0.788 and 0.913). The operative time was statistically significantly longer in the control group (p = 0.044), while the frequency of postoperative void dripping was much higher in the study group (p = 0.007).ConclusionThe success rate and complications of AAU for men with ultra-short penile urethral stricture were comparable to the dorsal buccal graft.

Comma-Shaped Columellar Strut for Nasal Tip Plasty in East Asian Rhinoplasty.

For East Asians, rhinoplasty procedures are predominantly focused on reconstructing a well-defined nasal tip. In this study, the authors present a new graft design for the columellar strut that is similar to the shape of a comma mark. As one integrated piece, the graft undertakes the roles of providing solid support for the tip, modifying different angles, as well as relationships between the tip and columella. One hundredand sixty-five female patients, ranging in age from 18 to 42years (average 27.1years), received augmentation rhinoplasty surgery over the past 4years with an average postoperative follow-up of 12months. Among these patients, 78 of them were primary cases and others were secondary or more. The cartilaginous framework was reconstructed based on comma strut with other grafts including spreaders and dorsal onlay grafts. Patients' own evaluations on the overall improvements of the nose rendered high satisfaction rate. During the long-term follow-up, 8 cases presented asymmetrical nostrils with slightly deviated columella; minor revision surgeries were performed. Another 3 cases presented dorsal graft warping and were also corrected. No other major complications were encountered. The comma strut provides a reliable support for the nasal tip; its dual curved structure plays the instrumental role in defining the lobular-columellar angle as well as modifying the supratip break. This graft design offers good control of tip and columella; as a result, consistent, reproducible results can be achieved. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The utilization of diced cartilage-fascia (DC-F) graft in the augmentation rhinoplasty of a case with Binder syndrome

The Binder syndrome is a congenital anomaly mostly seen in females characterized by a flat facial profile and flat nose with absent nasal spine, short columella, flat nasal dorsum, hypoplastic lower lateral cartilages (LLC) and septum, class-III malocclusion, and cleft lip and palate. A 26-year-old female patient with a Binder syndrome was referred to the clinic with a flat nasal dorsum, hypoplastic LLC, deformed nostrils, and hypoplastic columella. She had a history of bilateral cleft lip and palate, ocular strabismus, hypothyroidism, and growth retardation. An augmentation rhinoplasty with an open approach was performed in January 2019. The seventh costal cartilage and the rectus fascia were preferred as autologous grafts. An extended columellar strut graft was prepared and fixed to the nasal spine. Two lateral crural strut grafts was prepared and placed. The hypoplastic LLC were fixated to these grafts. A dorsal onlay graft was settled. Then, the diced cartilage-fascia (DC-F) graft was prepared and it was settled in over the nasal dorsum. A smaller and spherical DC-F graft was constructed to be placed over the extended columellar strut graft for increasing the tip projection. One-year postoperative results of this case confirm that the DC-F graft conserved its volume and shape. The growth retardation has not been described in Binder syndrome in the current literature, and this is the first case of nasal augmentation with DC-F graft in Binder syndrome. DC-F graft is a reliable alternative for the augmentation of the nasal dorsum in Binder syndrome. Level of evidence: Level V, therapeutic study.

76 The Effect of Splinting of Metacarpophalangeal Joints After Skin Grafting: A Review of the ACT Database

Abstract Introduction Hands are the most common area of the body to sustain a burn injury. Maintaining motion and function throughout the healing process of a burn injury is one of the most important goals of the rehabilitation process. After a deep burn to the dorsal aspect of the hand requiring skin grafting, the adjacent metacarpophalangeal (MCP) joints are at risk for developing a burn scar contracture (BSC), limiting the joints’ ability to fully flex towards a fist position. Post-operative positioning protocols state that patient’s hand should be temporarily immobilized for graft protection. A resting hand splint is used to maintain the wrist in approximately 20–30 degrees of extension, MCP joints at approximately 50–70 degrees of flexion and the interphalangeal joints in full extension. The purpose of this study was to assess the benefit of splinting as a treatment intervention to prevent MCP joint extension contractures following dorsal hand skin grafting. Methods This was a retrospective review of prospectively collected observational data from the “Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Time Related to Patient Outcomes” (ACT) study. Patients were included with grafted dorsal hand burns occurring within 1 of the 4 established cutaneous functional units (CFU) along the dorsal aspect of the second through fifth metacarpals. Since most subjects had more than one dorsal hand CFU involved, the number of CFUs were analyzed as opposed to the number of subjects. Isolated MCP joint flexion measurements were utilized to determine incidence of contracture. Included causes of contracture were scar tissue or other soft tissue limitations. Data were then analyzed by two groups: contracted and non-contracted. Results A total of 221 dorsal hand CFUs were included in this study; 119 contracted and 102 non-contracted. There was no statistical significant difference between the average splint wear time between the 2 groups. The average percent of affected CFUs grafted within the contracted group was 92.4% compared to 76.8% in the non-contracted group. In burns to the dorsal hand with less than 99% of the CFU grafted, splinting was effective in preventing 60% of MCP joint extension contractures. When greater than 99% of affected CFU was grafted, splinting was effective in prevention only 36% of contractures. Conclusions Splinting can be an effective intervention option in preventing MCP extension contractures when less than 75% of the affected CFU has been grafted; however, its effectiveness decreases as the percentage of CFU involvement increases to greater than or equal to 99%. Applicability of Research to Practice Determine most effective post-operative rehabilitations plan following dorsal hand skin grafts.

A Simple Combination Approach for Costal Cartilage Augmentation Rhinoplasty.

Autologous costal cartilage graft is optimal for augmentation rhinoplasty but with complications including markedly visible graft margins and dorsal contour irregularities. Therefore, the authors introduced the diced costal cartilage graft to smoothen the margins of bilateral spreader graft for nasal dorsum augmentation. A total of 6 patients were recruited for this augmentation rhinoplasty. The pre- and postoperative photographs were taken for improvement evaluation. During a mean follow-up of 15 months, none of the patients developed major complications that may require removal or revision of the costal cartilage grafts. Five patients (80%) were very satisfied with the aesthetic outcome. This simple algorithm facilitates the substantial augmentation and removes the visibility of dorsal graft in the costal cartilage rhinoplasty for the East Asian population.

Management of male anterior urethral strictures in adults. Results from a national survey among urologists in Spain

Introduction and objectiveAssessment of urethral stricture (US) management seems important to evaluate the quality of attention and plan educational interventions. We aim to investigate the practice patterns on diagnostic and therapeutic approaches to adult male anterior US among urologists in Spain. Materials and methods23-question on-line survey conducted among all members of AEU (Spanish Urological Association). Demography data and practices on evaluation and treatment of US were included. 1737 invitation letters sent by email, with 21.7% response rate. Data were prospectively collected during 2016. Descriptive analysis and univariate comparisons conducted using X2 test. Statistical significance considered when P ≤ 0.05. ResultsResponders were mainly from Tertiary and Teaching University Hospitals. 63.2% treated ≥10 patients/year with US. Retrograde urethrogram (RUG) was the commonest diagnostic tool followed by uroflowmetry (UF), and internal urethrotomy under direct vision (DVIU) the most frequent treatment. 84.4% limited DVIU for US ≤ 1.5 cm. 62.3% performed ≤5 urethroplasties/year. Anastomotic urethroplasties were performed by 75.7% and graft repairs by 68.9%. Dorsal grafting was preferred rather than ventral. Non-transecting techniques were used by 23.9%. UF was the most common follow-up tool. 88.4% felt that referral units were required. Tertiary hospitals used Patient Reported Outcome Measure (PROM) questionnaires more frequently than secondary centres. High-volume urologists were more likely to use non-transecting techniques and to choose urethroplasty as first choice procedure. ConclusionsMale anterior US in Spain are treated by many urologists, mainly using endoscopic procedures. RUG is preferred for diagnosis, and UF for follow-up. A high percentage of urologists perform urethroplasties, mainly anastomotic repairs, but in low volume.

Management of Dorsal Graft and Implant Infections.

Deficiency of the nasal dorsum can result from several etiologies, most commonly congenital, traumatic, or iatrogenic. The use of dorsal grafts or implants for augmentation of the dorsum is a mainstay of both functional and cosmetic rhinoplasty. Due to the cosmetically sensitive nature of the dorsum, and the relatively large amount of graft or implant material that is typically used, infections in this area can be particularly difficulty to manage. Here, we review the current literature on dorsal graft and implant infections, along with options for management.

Manejo de la estenosis de uretra anterior del varón. Resultados de una encuesta nacional entre urólogos que ejercen en España

Introduction and objectiveAssessment of urethral stricture (US) management seems important to evaluate the quality of attention and plan educational interventions. We aim to investigate the practice patterns on diagnostic and therapeutic approaches to adult male anterior US among urologists in Spain. Materials and methods23-question on-line survey conducted among all members of AEU (Spanish Urological Association). Demography data and practices on evaluation and treatment of US were included. 1737 invitation letters sent by email, with 21.7% response rate. Data were prospectively collected during 2016. Descriptive analysis and univariate comparisons conducted using X2 test. Statistical significance considered when P≤.05. ResultsResponders were mainly from Tertiary and Teaching University Hospitals. 63.2% treated≥10 patients/year with US. Retrograde urethrogram (RUG) was the commonest diagnostic tool followed by uroflowmetry (UF), and internal urethrotomy under direct vision (DVIU) the most frequent treatment. 84.4% limited DVIU for US≤1.5cm. 62.3% performed≤5 urethroplasties/year. Anastomotic urethroplasties were performed by 75.7% and graft repairs by 68.9%. Dorsal grafting was preferred rather than ventral. Non-transecting techniques were used by 23.9%. UF was the most common follow-up tool. 88.4% felt that referral units were required. Tertiary hospitals used Patient Reported Outcome Measure (PROM) questionnaires more frequently than secondary centres. High-volume urologists were more likely to use non-transecting techniques and to choose urethroplasty as first choice procedure. ConclusionsMale anterior US in Spain are treated by many urologists, mainly using endoscopic procedures. RUG is preferred for diagnosis, and UF for follow-up. A high percentage of urologists perform urethroplasties, mainly anastomotic repairs, but in low volume.

Single-stage buccal mucosal graft urethroplasty for meatal stenoses and fossa navicularis strictures: a monocentric outcome analysis and literature review on alternative treatment options.

To describe the operative technique and report outcomes from the largest series of patients who underwent single-stage dorsal inlay buccal mucosal graft urethroplasty (BMGU) for isolated meatal stenoses and fossa navicularis strictures. First, we evaluated patients who underwent single-stage BMGU for distal urethral strictures (meatus and fossa navicularis) between 2009 and 2016 at our department. Clinical and surgical characteristics were prospectively collected in an institutional database. Recurrence was defined as symptomatic need of any instrumentation during follow-up, was retrospectively assessed by patient interview, and recurrence-free survival was plotted using Kaplan-Meier curves. Second, a systematic literature review was performed through Medline to summarize the available evidence on distal urethroplasty using flaps or grafts. Of 32 patients, 16 (50%) presented with a hypospadias-associated stricture, followed by seven (22%), five (16%), and four (13%) patients with iatrogenic, inflammatory, and congenital strictures, respectively. At a median follow-up of 42months (IQR 23-65), single-stage dorsal inlay BMGU was successful in 22 patients (69%), and estimated recurrence-free survival rates were 79% and 74% at 12 and 24months, respectively. Overall, 62 patients from five studies in the literature review underwent BMGU for isolated distal strictures and success rates ranged from 56 to 100%. Recurrent meatal stenoses and fossa navicularis strictures represent some of the most complex uro-reconstructive challenges. Inlay BMGU proves to be a valid and efficient last-resort single-stage technique. However, higher recurrence risk must be considered and staged urethroplasty should be discussed individually. Prospective randomized controlled trials are needed to prove the superiority of flaps, grafts or staged approaches over each other in this context.