Inferior Flap Research Articles

"Open-window" craniectomy for the removal of frontal sinus mucosa to prevent a delayed mucocele: illustrative case.

Frontal craniotomies for a medial subfrontal approach necessitate crossing the frontal sinus. Large superior extensions of the frontal sinus into frontal bone can result in mucosal retention in a free craniotomy bone flap, leading to a delayed mucocele with significant associated morbidity. The authors describe an "open-window" craniectomy technique that permits mucosal removal under direct vision and maintains the inner table on the bone flap's inferior side, helping to seal off the sinus opening with a pericranial flap. An illustrative case involving a medial right frontal craniotomy for a third ventricle mass in a patient with a large superior extension of the frontal sinus into frontal bone is presented. After creating a free frontal bone flap, the inner table was drilled out to the margins of the frontal sinus cavity and any remaining mucosa was cleared. A portion of the inner table above the bone flap's inferior margin was left in place, resembling an open window when viewed from the inner table side. The remaining anterior and posterior wall of the flap inferiorly provided a matched surface for the opening into the remaining frontal sinus, which was covered by pericranium. Long-term follow-up indicated no major complications or delayed mucocele. The open-window craniectomy technique can be considered for frontal sinus violations in patients with large superior frontal bone extension.

Minimally Invasive Open Cystogastrostomy for Giant Pancreatic Pseudocyst in Pediatric Patients.

Open cystogastrostomy is the standard treatment for the operative management of pancreatic pseudocysts. We describe our technique of minimally invasive open cystogastrostomy for giant pediatric pancreatic pseudocyst. Preoperative incision marking on the most prominent part of the pseudocyst was done by ultrasound guidance. A transverse incision of approximately 3-4 cm was made, and a minilaparotomy was performed. Stay sutures were applied on the anterior wall of the stomach. The anterior wall was exteriorized; transverse gastrotomy was performed, and superior and inferior flaps were made. Deaver's retractor was placed inside the lumen, and cystogastrostomy was completed. We employed this technique in five male patients without any complications. All patients were allowed clear liquids on postoperative day 4 or 5; and gradually shifted to a soft diet. The mean duration of postoperative stay was 7 days. The size of the scar ranged from 3 to 5 cm. All patients were doing well on follow-up. Our technique of minimally invasive open cystogastrostomy is a viable option for pancreatic pseudocyst in pediatric patients.

Superior versus inferior conjunctival rotational flap in primary pterygium surgery

Background Conjunctival rotational flap is one of the surgical treatment options for pterygium with variable recurrence rates. Taking a conjunctival flap from the superior bulbar area is sometimes unfeasible due to scarring, ocular surface disease, or previous trabeculectomy. Aim This study aimed to compare the superior versus the inferior conjunctival rotational flap results following primary pterygium excision. Patients and methods This is a retrospective, interventional, comparative study that enrolled 120 patients having primary pterygium. The patients were recruited from the Ophthalmology Department, Beni Suef University Hospital, Beni Suef, Egypt during the period from June 2020 to June 2022. The patients were classified into two groups: group I that included 73 (60.8%) patients who underwent the superior conjunctival flap technique, and group II that included 47 (39.2%) patients who underwent the inferior flap technique. Slit-lamp findings were reported during the scheduled appointments, with a focus on pterygium recurrence and other complications. Postoperative follow-up was performed for 6–18 months. Results The recurrence rate among the inferior conjunctival flap group (12.8%) was higher than in the superior conjunctival flap group (9.6%), with no statistically significant difference (P=0.585). No additional postoperative complications, such as flap separation, dullen formation, or granulomas occurred in either group. Conclusion There was no statistically significant difference in the outcome of the superior and inferior conjunctival rotational flaps in primary pterygium excision. We propose that inferior conjunctival flap preference can result in favorable outcomes in circumstances where the superior bulbar conjunctiva is required for protection or cannot be used.

Endoscopic Reconstruction of the Sellar Floor by Extended Inferior Turbinate Flap in Recurrent Pituitary Tumors.

Objective This aim of this study was to address the outcome of endoscopic reconstruction of the sellar floor by extended inferior turbinate flap. Patients and Methods This is a retrospective study of 34 patients with a recurrent pituitary tumor. They were treated between March 2018 and December 2021 by endoscopic extended endonasal approach with the reconstruction of the sellar floor by an extended posterior pedicle inferior turbinate flap. The clinical and radiological follow-up was performed immediately postoperation and regularly every 3 months up to 1 year, and the available data from the last follow-up visit were included in the analysis. Results The patients' age ranged between 40 and 65 years, with a slight female predominance (55.9%). Headache was the main presentation (47.1%), and functional tumors were found in 50.0% patients. Visual disturbances were field defects among 61.8% and papilledema among 52.9% patients. Preoperative endoscopy revealed postseptectomy as the significant finding (73.5%), followed by postseptectomy and adhesion (14.7%) and finally postseptectomy and hypertrophied inferior turbinate (11.8%). Total tumor resection was achieved in 76.5%, visual improvement was recorded in 52.9%, and no complications were reported in 82.4% patients. Cerebrospinal fluid (CSF) leak was not reported in any of the studied patients. Finally, total resection was significantly associated with younger age, non-functioning tumor and improvement of headache. Conclusion The extended inferior turbinate flap is an effective and safe approach for sellar floor reconstruction in endoscopic endonasal surgery for recurrent pituitary tumors. The extension overcomes the relatively small inferior flap and its limited arc of rotation.

A Comparative Study Between Anterior–Posterior and Superior–Inferior Flap Suturing Technique in Endoscopic Dacryocystorhinostomy at our Tertiary Institution

A Comparative Study Between Anterior–Posterior and Superior–Inferior Flap Suturing Technique in Endoscopic Dacryocystorhinostomy at our Tertiary Institution

The end of tracheostomal stenosis? Introducing the fish mouth technique.

Post-laryngectomy tracheostomal stenosis is common and often results in an inadequate airway. Several techniques have been described to minimise tracheostomal stenosis. The star technique involves an 'X' incision with four flaps sutured into the trachea. The petal technique involves two inferior flaps on either side being sutured into the trachea. The authors combined the star and petal techniques, resulting in an innovative fish mouth technique. This innovation involves two lateral skin flaps being sutured into an incision on either side of the lateral wall of the trachea. This results in an elongated, broadened and elliptical tracheostoma, mimicking that of a fish mouth. Benefits of the fish mouth technique include adequate stoma size for respiration, easier clearing of secretions, self-sufficiency without a stent, easier cleaning of a tracheoesophageal voice prosthesis, and stoma occlusion for voice production. The fish mouth technique is easily reproducible and suitable for those with a voice prosthesis.

The Open Capsular Shift-Latarjet Procedure for Recurrent Anterior Shoulder Instability

Background: Capsular management is having an increasingly important place during the open Latarjet procedure especially in preventing postoperative glenohumeral arthritis. The open capsular shift-Latarjet procedure consists of the classic Latarjet procedure associated with a glenoid T-based capsular shift to treat patients with high risk of recurrent anterior shoulder instability. Indications: Patients presenting with humeral and/or glenoid bone loss, patients practicing professional activities or sports at risk of recurrence and without any previous capsular surgery, or major capsular deficiency. Technique Description: After a classic deltopectoral approach and the osteotomy of the coracoid process, a horizontal split of the subscapularis is performed. Then a glenoid T-based capsulotomy is performed, and 2 passing wire suture threads are passed through the inferior flap of the capsule to prepare the capsular shift. A first, soft, all-sutured anchor is inserted at the inferior part of the glenoid medially to the articular surface. The coracoid graft is then positioned with a first inferior cancellous screw to be flush with the articular surface and fixed using a second cancellous screw. A second anchor is placed laterally and superiorly to the coracoid at the anterior scapular neck. The capsular shift is performed using a passing wire technique to suture the capsular flap to both anchors and to ensure the extraarticular positioning of the coracoid. Results: Bouju et al found a low rate of recurrence with no revision surgeries and a significative lower incidence of osteoarthritis (8.6%) at 10-year follow-up compared with the current literature when suturing the capsule to the coracoid process. Itoigawa et al concluded that suturing the capsule on the coracoid may increase the risk of osteoarthritis due to a direct contact between the humeral head and the transferred coracoid, thus we suggest attaching the capsule over the glenoid. Discussion/Conclusion: With appropriate patient selection, this technique is safe and reliable to treat patients with anterior instability without any specific risk related to the surgery. The association of the capsular repair is an appropriate solution to better restore the anatomy and to prevent the long-term risk of glenohumeral arthritis.

Goldilocks Procedure without a Vertical Incision and a Comprehensive Literature Review.

Background:The Goldilocks technique is a postmastectomy breast reconstruction procedure adopted in 2012, which is performed by preserving and de-epithelializing the residual mastectomy flap to create an autologous tissue breast mound using an anchor, inverted T, or lateral incision. It is utilized in select patients along with the addition of a free nipple graft, fat grafting, and/or tattoo. A novel technique using the Goldilocks procedure offers promising postoperative results as a more aesthetic alternative. The purpose of this study was to perform a literature review on the healing outcomes and patient satisfaction of the Goldilocks procedure along with presenting our approach using a horizontal inframammary incision without a vertical incision.Methods:A retrospective chart review of patients presenting to a single surgeon for breast reconstruction surgery using the Goldilocks procedure without a vertical incision from March of 2018 to October of 2020 was performed. A narrative literature review on surgical techniques and outcomes was also conducted.Results:Three cases of breast reduction using the Goldilocks procedure without a vertical incision are described. From the literature search, 13 articles inclusive of 222 patients were identified.Conclusions:The Goldilocks procedure without a vertical incision can be performed in patients with large breasts for breast reconstruction postmastectomy. It is possible to utilize the superior flap in conjunction with the de-epithelialized inferior flap of the breast and obtain good projection with this method. Furthermore, avoidance of the vertical incision reduces breakdown at the T-junction and is aesthetically beneficial.

Free Flap Reconstruction of Extremity Defects in Pediatric Patients

Abstract Background Microsurgical reconstruction of extremity defects with free flaps has been carried out for many years. The aim of this retrospective study is to characterize free flap surgery on children of 1 to 7 years old by evaluating a series of 20 cases of free flap surgeries that have been performed in pediatric patients. Methods From February 2014 to January 2018, 20 patients, 10 boys and 10 girls aged from 1 to 7 years (average, 4.6 years), were engaged in this study. Several types of free flaps were used, including anterolateral thigh flaps (ALT), inferior ulnar collateral artery flap, latissimus dorsi flap, medial plantar flap, fibular osteocutaneous flap and hallux toenail flap. After operations, follow-up period was at least for 2 years and the average follow-up period was 48.5 months. The long-term outcomes were estimated by questionnaires derived from the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI). Results A total of 21free-flap reconstructions were performed on 20patients, including 15 ALT, 3 composite flaps, and 3 other cutaneous flaps. The size of the tissue flap ranged from 1.5 to 280 cm2 (average, 74.1cm2). The diameter of the anastomosed artery of the flap ranged from 0.7 to 1.2 mm. Among the 21 flaps, 20 survived and the success rate was about 95 %. Contour adaption was achieved in all flaps. Fifteen children received a secondary operation for debulking or functional improvement. Secondary deformity was present in 3 children, among which ankle joint valgus was seen in two children and a flexion deformity of injured toe occurred in one child. The mean global functioning score of PODCI was 94 (ranging from 81 to 98, maximum 100). Conclusion The success rate of free-flap surgery in pediatric patients was comparable to that achieved in adults. Post-operative caring for pediatric patients was easier than expected. For pediatric patients, the final outcomes were not varied remarkably from different types of free tissue transfer.

Upper Lip Reconstruction Utilizing a Two-Stage Approach with Nanofat Grafting After Hemangioma Treatment.

Importance: Lip deformities that occur after treatment of vascular anomalies treatment are often followed by serious local cicatricial adhesion and mucosa atrophy that can complicate reconstruction methods involving simple fat grafting or local flap transfer. Objective: To develop a novel technique that combines flap transfer with nanofat grafting that can be used to reconstruct the upper lip after treatment of vascular anomalies. Design, Setting, and Participants: A retrospective study of a consecutive series of 24 patients with upper lip deformities (13 female and 11 male) aged between 7 and 24 years old was conducted. Of these, 15 patients were treated with nanofat grafting alone and 9 cases were treated with nanofat grafting combined with flap transfer (6 inferior- and 3 superior-based flaps). Main Outcomes and Measures: The appearance, symmetry, and smooth of upper lips with deformities before and after surgery were compared as the main outcome. Results: Among the patients examined, 15 achieved satisfactory results after undergoing multiple nanofat grafting treatments. The remaining nine patients who had serious deformities of the upper lip were treated using a combination of nanofat grafting and flap transfer. For these nine patients, postoperative results showed that the final appearance of the lips was generally symmetrical and smooth. Functional problems such as whistling defects were effectively corrected and no significant complications occurred. The aesthetic symmetry was higher for inferior flaps than for superior flaps and the incision scar for superior flaps was more obvious than for inferior flaps. Conclusion and Relevance: The technique combining nanofat autografting with local flap transfer for upper lip reconstruction was demonstrated to be effective, safe, and simple to perform. These findings suggest that this combined technique can be easily performed to achieve good results with only mild undercorrection.

Combined Superior and Inferior Dermoglandular Flaps for Projection Enhancement in Gigantic Breast Amputation and Free Nipple Areola Graft

Background: Breast amputation and free nipple areolacomplex (NAC) graft is reserved mainly for cases of gigantomastia.This technique usually ends by flat boxy breastwithout projection. Many flaps have been used to overcomethe flat boxy breast. The superior and inferior flaps were usedin 20 cases of gigantomastia during the period between March2014 and October 2018. The technique, results, and complicationswill be presented and discussed.The Aim of the Work: The aim of this study is to emphasizethe efficacy of using combined superior and inferior flaps forprojection enhancement in breast amputation and free NACgraft surgery.Patients and Methods: A prospective study was conductedon 20 cases of gigantomastia at Al-Azhar University Hospitals.The classic breast amputation was done in conjunction withelevation of superior and inferior flaps. The average dimensionsof the flaps were 8x13cm. The free ends of both flaps weresutured together and fixed to the pectoral fascia by sutures atthe upper part of the breast. The procedure was completed asa wise pattern technique and ended by an inverted T scar. Allpatients were followed-up for a period of 6 months.Results: Regarding projection enhancement which is themain target of this study, all cases showed increases projectionthat ranged from excellent in 14 cases (70%) to good in 6cases (30%) according tothe designed questionnaire.Conclusion: Adding superior and inferior dermoglandularflaps in breast amputation and free NAC graft enhances breastprojection, decreases the boxy appearance and bottoming outrate of breast.

AB021. SOH21AS219. Perineal reconstruction following oncological extended rectal surgery: the role of the inferior gluteal artery myocutaneous flap

AB021. SOH21AS219. Perineal reconstruction following oncological extended rectal surgery: the role of the inferior gluteal artery myocutaneous flap

The Benefits and Pitfalls of Using an Autologous Dermal Flap in Immediate Implant-Based Reconstruction.

One of the challenges of implant breast reconstruction post-subcutaneous mastectomy is coverage of the inferior pole of the implant to provide a barrier between the implant and skin. Numerous biological and synthetic meshes are available on the market for this purpose; however, they are often very costly and carry all the risks of using a foreign body. In patients with large ptotic breast, the skin of the inferior mastectomy flap can be used instead. A number of techniques and variations have been developed over the last 40 years driven by the increasing cost of healthcare and acceptance of breast reconstruction as vital part of breast cancer care and survivorship. This review outline the benefits and pitfalls of using an autologous dermal flap in breast construction and the variations in published use.

Endoscopic maxillectomy: anatomo-radiological description of the “double” maxillary sinus window

To present a modified endoscopic medial maxillectomy (MEMM) approach to control maxillary sinus pathologies. MEMM was completed in 13 fresh-frozen specimens. An MEMM includes cutting the nasolacrimal duct, inferior meatus flap, and repositioning the inferior turbinate (IT). The following measurements were obtained: length of IT, height from the nasal floor to valve of Hasner, height of the IT at the level of valve of Hasner, height of the IT at the insertion of the middle turbinate, and distance from the piriform aperture to the posterior wall of maxillary sinus and to the posterior border of palatine bone. Similar measurements were also performed on craniofacial computed tomography (CT) scans (n = 50). The surgical technique was performed in a case series (n = 8). The mean of the specimens was 82 (range 70–95) years old. The average area of the harvested inferior meatus flap area was 9.6 ± 1.0 cm2. In the radiologic study, the mean maximum antrostomy area was 8.8 ± 1.7 cm2 and the IT area overlapping the antral window was 5.8 ± 1.1 cm2, the area allowing a double window control was 3.1 ± 1.9 cm2, the posterior IT insertion length was 0.7 ± 0.4 cm, and the inferior meatus flap covering the inferior meatotomy had an area measuring 6.7 ± 1.7 cm2. Eight patients underwent MEMM for various benign conditions showing no recurrence after 26 month follow-up. The proposed modifications of MEMM provide a “double” window maxillary sinus control with access to all maxillary walls and preservation of the IT.

A novel technique to prevent the breast implant from exposure after mastectomies

Introduction After mastectomies, we do our reconstruction, either immediately or delayed. In both ways of reconstruction for post mastectomies defect, the most commonly performed reconstruction is by using breast prosthesis [1]. For many years, surgeons have been trying to find out any solution to reduce the rate of implant exposure and develop some new techniques and modifications. However, once the infection develops or implant expose the only permanent solution is to remove the implant [2-3]. Although there is less evidence found in the literature regarding the salvage of implant once the infection occurs and when implant becomes expose in implant-based reconstruction [4]. Radiation also plays additional role in post-operative complication rates following implant-based breast reconstruction, as it is well documented that the incidence of complications is to be higher in radiated breasts compare to similar non-radiated breasts [5]. With the new advancement in radiation therapy the number of patients have been increasing who are receiving radiation therapy after immediate breast reconstruction [5]. Description of the Technique For more than 15 years we have been reconstructing the breasts deformities after different types of mastectomies, ranging from skin sparing, nipple areola sparing to different types of lumpectomies, by immediate insertion of breast implants. The main problem which we face during post-reconstruction, is the exposure of implant in addition to infection. With the advent of ADM (Artificial Dermal Matrix) [6], serratus anterior muscle [7], rectus fascial flap [7] and inferior dermal flaps [8] although they do an addition to thickness of skin envelop over the implant after mastectomy, but still the rate of implant exposure has not changed noticeably. It has been well understood that of ADM expose in air it dries immediately which later on results in implant exposure. Meanwhile we have developed a novel tech- nique to augment the soft tissue coverage under the incision line over the ADM and implant. By this way, if there is any dehiscence over suture line, there will be no implant exposure as there is additional soft tissue layer of dermal flap. These dermal flaps are actually a de-epithelialized dermal flap from the inferior half of the breast skin, which we used to excise and throw it to the garbage, particularly in skin sparing mastectomies. In this technique we suture the inferior based dermal flap over the artificial dermal matrix in a way that suture lines of skin flaps of mastectomy lie over the de-epithelialized dermal flap, which actually in- crease the survivability of ADM as well as increase the thickness of soft tissue over the implant (figure 1 and 2). By addition of this layer of de-epithelialized dermal flaps over the artificial dermal matrix and breast implants have promising reduction effect over implant exposure as well as it provides the additional vascularized soft tissue layer over the implant. Although we are using dermal flap with ADM frequently in most of our skin spring mastectomies but we did this new technique in 2 patients till now with the mean follow up of 8 weeks till now there is not a single case report of implant exposure in those patients (figure 3).

Free tissue transfer for skull base reconstruction - a review

Evolutions in skull base surgery and reconstructive technique have given surgeons the confidence to resect and repair increasingly advanced skull base pathologies. Free tissue transfer (FTT) provides a versatile option capable of addressing numerous simultaneous reconstructive goals. This review highlights some of the nuances, challenges, and considerations of performing FTT for skull base reconstruction in the anterior, central and lateral skull base. This review combines the expert opinion of the senior authors with those of the field at large as queried through PubMed searches regarding skull base reconstruction and FTT. Reconstructive goals include separation of intracranial from extracranial cavities, obliteration of dead space, and protection of vascular and neural structures. Atypical vascular pedicle management is commonly needed, especially for endonasal and central skull base resection. Virtual surgical planning may be beneficial for complex bony reconstruction. Familiarity with common complications such as cerebrospinal fluid leak, nasocutaneous fistula, and inferior flap displacement, as well as associations for their development, can help plan the reconstruction to minimize morbidity.

Inferior Pedicled De-epithelialized Dermal Flap for Abdominal Wall Support in Recurrent Abdominal Hernias

A ventral hernia is a common complication that occurs after a laparotomy. It is also a major, common, and recurring complication in reconstructed hernias. Component separation, component separation + mesh, mesh only, and primary closure + mesh are among the often resorted procedures for ventral hernias. Although the importance of autologous tissue support is well-accepted, it is not often reported in the literature. Here, we presented a case and the technique, in which the ventral hernia treatment was supported with inferior de-epithelialized dermal flaps during abdominoplasty.

Oncoplastic breast-conserving surgery using chest wall perforator flaps: Three-dimensional quantitative analysis of the percentage of breast volume excised and changes over time in flap volume.

We investigated the effects of oncoplastic breast-conserving surgery (BCS) using chest wall perforator flaps (CWPFs) on the subsequent expected deformity and evaluated the longevity of flap volume. We retrospectively reviewed oncological and cosmetic outcomes of 33 women who had undergone the above procedure. We calculated the percentage of breast volume excised (PBVE) from computed tomography volumetry and compared it between a historical BCS alone and the study (flap) group. We also sequentially evaluated flap volumes by magnetic resonance imaging volumetry. Oncoplastic BCS using 25 lateral flaps and eight inferior flaps, depending on the site of the defect, was performed; mean PBVEs were 31.1% and 19.0%, respectively. No local and two distant recurrences occurred in a median follow-up of 61 months. PBVE was 2.6 times larger in the flap than in the BCS alone group. Over half the patients in the BCS alone group had poor cosmetic results when PBVE exceeded 15%, whereas patients in the flap group achieved good cosmetic results with PBVE >25%. In most patients, 80% of flap volume was maintained 5 years after surgery. CWPF improves cosmetic outcomes in patients with predicted deformity after BCS alone and maintains its volume for at least 5 years.

Surgical repair for transverse facial cleft: two flaps with a superiorly rotated single Z-plasty lateral to the commissure

Various techniques have been performed for repairing transverse facial clefts. This study aimed to investigate an optimal method for repairing transverse facial clefts. Twenty-seven patients from 2008 to 2017 were evaluated. Their mean age at repair was 6.7 months with a follow-up period of 6 months to 10 years. A method using an inferior lip-based triangular mucosa flap and a superior lip-based rectangular vermilion-mucosa flap was designed for transposition. The orbicularis oris was reconstructed by using everting mattress suture. The skin was sutured using linear cutaneous closure with a single superiorly rotated Z-plasty lateral to the commissure. A postoperative symmetrical commissure was obtained owing to complete contraction with the new commissure directed 2 or 3 mm medial to the symmetrical point on the lips individually for the 27 patients. Lateral displacement of the reconstructed commissure was not observed. The patients showed a plump and symmetrical cheek on the cleft side. Twenty-one patients with hemifacial microsomia achieved a prominent improvement compared with their preoperative appearance, although the postoperative cheeks still did not show fullness because of the lesser facial tissue on the cleft side. In the early follow-up period, most patients showed a minimal scar during movement. However, the scar became thinner and symmetrical oral movement was achieved over time. This method obtained a natural oral movement without a conspicuous scar and was reliable and remarkable for the postoperative appearance of commissural symmetry. We conclude that this is an optimal method to repair transverse facial clefts.

Colgajo de Antia-Buch para reconstrucción de defectos del borde helicial. Descripción de un caso.

Introduction and objective: The Antia-Buch flap is a procedure in which two chondrocutaneous flaps are used to reconstruct the helicial region of the auricular pinna. The laxity of the tissue is conferred, to a large extent, by the inferior flap and the chondrocutaneous resection of the scafa is required for closure. This results in the loss of the height of the ear. Our objective is to perform the exeresis of a medium-sized lesion without compromising the morphology of the auricular pinna. Description: We performed an Antia-Buch flap reconstruction in a patient with spinocellular carcinoma of the right helix.Results: Squamous cell carcinoma with free margins was removed obtaining a good aesthetic result of the auricular pinna. Discussion: The Antia-Buch flap is used for medium size defects of the helicial region. Among the different surgical steps, highlight the V-Y discharges to avoid tension in the tissues and conserve the perichondrium of the flap for chondral nutrition. Conclusions: Technique in which good aesthetic results are obtained, without compromising the radicality of the excision.