Local Mucosal Flaps Research Articles

Scoping Review of Surgical Rehabilitation of Post Intubation Phonatory Insufficiency.

Post intubation phonatory insufficiency (PIPI) or posterior glottic diastasis describes posterior glottic insufficiency (PGI) caused by prolonged intubation causing medial arytenoid ulceration, mucosal scarring, and incomplete cricoarytenoid joint adduction. The purpose of this review is to showcase diagnostic findings, surgical rehabilitation, and gaps in our treatment algorithm of PIPI. Embase, PubMed, Scopus, Web of Science. Two independent reviewers completed a systematic search of the literature studying PIPI. Reported intubation history, laryngeal defect, clinical symptoms, surgical intervention, and outcomes were gathered from included studies. Nine studies met our inclusion criteria for full review, (45 patients) all of which were case reports/series. All patients had posterior glottic defects, most commonly loss of medial arytenoid tissue, causing varying degrees of PGI. Eleven patients had vocal fold (VF) immobility or hypomobility. Treatment interventions were observation (1), speech therapy (2), VF or posterior glottic injection augmentation (15), medialization laryngoplasty (4), arytenoid repositioning (6), endoscopic (19) or open (3) posterior cricoid reduction, local mucosal rotation flap (11), or free mucosal graft (2) to fill the glottic defect. Observation, voice therapy, and augmentation or type 1 laryngoplasty failed to improve symptoms. Other surgical techniques improved symptoms with varying outcomes. PIPI is a difficult injury to diagnosis and treat. Conservative measures and augmentation/laryngoplasty often fail to fix the PGI. Our review supports symptom improvement with reconstruction of the posterior glottic defect with cricoid reduction or mucosal grafts. Future investigation is needed to better define the diagnosis and successful treatment algorithm. Laryngoscope, 134:2048-2058, 2024.

Surgical Method for Glottic Web and Vocal Fold Adhesion

Laryngeal web most frequently occurs due to acquired rather than congenital factors. It can cause dysphonia and airway disorder depending on the extent of the area or thickness of the web. The prevention of relapse after web resection is the most important aspect of surgery for laryngeal web. A local mucosal flap can be developed using the superior and inferior surface of the web. This flap can cover at least one side of the wound on the vocal fold after web resection, and consequently leads to primary healing. The other technique for preventing web relapse is to place a stent (also called a “keel”) at the anterior commissure after removing the web. A slim silicone tube can be used as a stent to prevent web relapse. A membrane like plate can also be adopted. The round-shaped silicone tube has an advantage in softness for the vocal fold in comparison to a flat-shaped plate. One of the disadvantages of the silicone tube is that it cannot cover the wound that develops after the resection of a broad web affecting the posterior membranous vocal fold. To resolve this problem, we developed a new type of silicone stent that includes both a tube and a plate component. An appropriate surgical method and stent should be chosen based on the condition of the web.

Effectiveness of the lateral pedicled endonasal flap for prevention of restenosis in frontal sinus drillouts.

Frontal sinus median drainage according to Draf is an established procedure for achieving maximum drainage of the frontal sinus. Despite great efforts and several modifications, restenosis of the neo-ostium is still a persistent problem. This study presents an approach by implementing local mucosal flaps to prevent restenosis and compares it with the conventional technique without using the flap. Description of endonasal, lateral pedicle mucosal flap. A Draf III procedure was performed on 156 patients between 2012 and 2021. Data for 123 of the included patients were retrospectively analyzed in terms of surgical indication, technique, postoperative aftercare and patency of the drainage pathway. The follow-up observation period was between 3 and 24 months. Treatment with the pedicle mucosal flap took place in 86 cases. 37 patients were treated as a control group without this flap. The analysis showed a significant association to the event "total closure of the drainage pathway" for surgical technique, as well as in the case of the presence of an allergy and the existence of Samter's triad. Furthermore, there was a significant association between the onset of "near total closure of the frontal sinus ostium" and Samter';s triad, CRS and revision surgery was involved. Use of an endonasal lateral pedicle flap for reconstruction of mucosal defects in frontal sinus surgery improves the long-term chances of a patent drainage pathway. Bone exposed by drilling was covered with a local mucosal flap for a faster epithelialization, healing and less scarring.

Endonasal Acoustic Doppler Sonography in Predicting the Survival of Nasoseptal Flap Following Previous Irradiation.

Blood supply to the nasoseptal flap may be compromised in patients who had previous irradiation to the head and neck region, hence, affecting its viability. Here, we evaluate the role of an endonasal acoustic Doppler sonography in predicting the survival of the nasoseptal flap in this group of patients. Retrospective cohort. Retrospective review of patients with previous irradiation to the head and neck region who had undergone endoscopic endonasal surgeries requiring nasoseptal flap as reconstruction. Survival rates of nasoseptal flap were compared between groups where endonasal Doppler was used. A total of 28 patients were identified with previous irradiation to the head and neck region who had undergone endoscopic endonasal surgeries requiring nasoseptal flap as reconstruction. The overall survival rate of nasoseptal flap is 67.8% (19 out of 28). Endonasal acoustic Doppler was used in 17 of these patients, of which 13 patients had a positive signal. The flap survival rate in the Doppler-positive group compared to the non-Doppler group was significantly better at 100% vs 45.4% (P= .003). Among those where the endonasal Doppler was used, the flap survival rate with a negative doppler signal was significantly worse at 25%, compared with 100% flap survival in those with positive doppler signal (P= .006). The positive predictive value of a positive endonasal Doppler signal with flap survival is 100%. The use of endonasal acoustic Doppler may be useful in predicting the viability of nasoseptal flap in postirradiated patients who need a local mucosal flap coverage. 3 Laryngoscope, 133:244-247, 2023.

"NIMS" nasal mucoperiosteal flap for sublabial trans-sphenoidal surgical defect repair: A new technique under microscope.

Background: CSF rhinorrhea is a known complication that may occur after cranial base surgery, especially the trans-sphenoidal approaches to sellar tumors. It may occur following both microscopic and endoscopic procedures. Over a period, the balance has tilted toward endoscopy due to development of pedicled Hadad flap. Microscopic trans-sphenoidal surgery (TSS) continues to be performed in our institute as well as many other centers across the world due to familiarity of technique and unavailability of endoscopic equipment. Despite the fairly widespread use of this surgery, literature is devoid of any description of a local mucosal flap for repair of the surgical defect in microscopic TSS.Methods: We herein described the procedure and our experience of harvesting such flap in 42 patients operated for pituitary adenomas in our department between September 2016 and February 2020, through microscopic sublabial TSS.Results: All 42 of the patients included in this study underwent excision of pituitary tumors (macroadenomas). Thirty-nine (n = 39) patients were undergoing 1st time surgery, while three (n = 3) of these patients were undergoing second surgery following an earlier trans nasal trans-sphenoidal route. None of our cases have reported CSF leak postoperatively.Conclusion: This study attempts to highlight to ardent/obligate microscopic surgeons that a local vascularized flap can be harvested for repair of skull base defect and prevent postoperative CSF leak in microscopic sublabial TSS.

Locoregional Flap Reconstruction Following Oromaxillofacial Oncologic Surgery in Dogs and Cats: A Review and Decisional Algorithm.

Primary treatment of most oromaxillofacial tumors in dogs and cats is resective surgery. Management of malignant tumors may be very challenging as wide/radical free-margin surgical removal must be achieved while preserving vital functions. Removal of orofacial tumors may result in large defects exposing the oral cavity or creating a communication with the nasal, pharyngeal, or orbital cavities. Such defects require orofacial reconstruction in order to restore respiratory and manducatory functions. The veterinary surgeon must be familiar with reconstructive techniques in order to prevent the inability of closing the defect, which could lead to an insufficient resection. Small oral defects exposing the nasal cavity are best closed with local random mucosal flaps. Closure of large oral defects may be better achieved with a facial or major palatine-based axial-pattern flap. Small to moderate facial defects can be closed with local advancement or transposition skin flaps. Reconstruction of large facial defects often requires the use of locoregional axial pattern flaps such as the caudal auricular, the superficial temporal, or the facial (angularis oris) myocutaneous axial pattern flaps. Recent publications have shown that the facial (angularis oris) flap is a very versatile and reliable flap in orofacial reconstructive surgery. A surgical decision algorithm based on the size, nature, and location of the defect is proposed.

Closure of skull base defects after endoscopic endonasal transsphenoidal surgery: the role of the local sphenoid mucosal flap for low flow leaks.

A local sphenoid mucosal flap (SMF) is naturally raised during endonasal exposure of the sella. Typically, these flaps are repositioned; however, they could be used in place of a nasoseptal flap (NSF) for closure of low-grade CSF leaks. In this study, we aim to establish the safety and efficacy of SMF closure for low-grade CSF leaks and to assess the impact on sinonasal quality of life (QoL) compared to NSF closure. In a consecutive, prospective cohort of anterior skull base pathology, data regarding sellar and suprasellar extension (Hardy grade), cavernous sinus invasion (Knosp grade), intraoperative (Kelly grade) and postoperative CSF leak, and sino-nasalQoL data (SNOT-22) were analysed. Of 187 patients with no/low flow (Kelly 0-1) intraoperative CSF leak, 127 (67.9%) received a SMF and 60 (32.1%) received a NSF. A total of 141/187 (75.4%) had nointraoperative leak, while 46/187 (24.6%) had grade-1 leaks. SMF were used in 70.9% (100/141) of cases without intraoperative leak, and 58.7% (27/46) of cases with Kelly grade-1 leaks. Hardy grade 4, grade E and Knosp grade 4 lesions were all more commonly closed with a NSF (p < 0.05). Two patients (1.1%) had postoperative CSF leaks, both in the SMF group, and both after no discernibleintraoperative leak. Sinonasal QoL was below baseline for up to 3months postoperatively. SMF cases tended to have better sinonasal QoL for up to 6weeks after surgery. Thus, in the largest cohort to date, SMF are a safe alternative to NSF for closure low-grade skull base defects. Sinonasal QoL was better in the first 6weeks after SMF closure than NSF closure.

Local mucosal flap for the treatment of gingival defect after gingival fibromatosis excision

Local mucosal flap for the treatment of gingival defect after gingival fibromatosis excision

Lip Shaving in Carcinoma Lower Lip and Reconstruction by Local Advancement Mucosal Flap Under Local Anesthesia: A Case Report

The lips are one of the most important features of the face; and are functionally and aesthetically very important. It serves as border of the oral commissure, provides access to oral cavity and contributes to oral competence. It is important for verbal expression and fundamental for facial expression and overall appearance of face1 . Excessive sun exposure and tobacco use, may develop cancer. The cancer can occur anywhere along the upper or lower lip, but is most common on the lower lip. Most lip cancers are squamous cell carcinomas. Surgery is the main stay of treatment and lip shave is an established modality for superficial lesion followed by reconstruction. Extensive surgery may be necessary for larger lesion. Careful planning and reconstruction can restore eating and speaking normally, and also achieve a satisfactory appearance after surgery. Evidence supports that the concept of lip reconstruction started as early as 1000 BC in the sacred texts of great Susruta, India2 . Lip mucosa is very special and it is recommended to reconstruct the surgical defect with lip tissue whenever possible, as any other tissue is never comparable or can replace the lip tissue3 . This is the example of this presented case.

Reconstruction of microstomia considering their functional status.

Background Microstomia is defined as a condition with a small sized-mouth that results in functional impairment such as difficulty with food intake, pronunciation, and poor oral hygiene and cosmetic problems. Several treatment methods for microstomia have been proposed. None of them are universally applicable. This study aims at analyzing the cases treated at our institution critically reviewing the pertinent literature.Methods The medical records of all microstomia patients treated in our hospital from November 2015 to April 2018 were reviewed retrospectively. Of these, all patients who received surgical treatment for microstomia were included in the study and analyzed for etiology, chief complaint, surgical method, and outcomes. The functional outcomes of mouth opening and intercommissure distance before and after the surgery were evaluated. The cosmetic results were assessed according to the patients’ satisfaction.Results Five patients with microstomia were corrected. Two cases were due to scar contracture after chemical burn, two cases derived from repeated excision of skin cancer, and one patient suffered sequela of Stevens-Johnson syndrome. The following surgical methods were applied: one full-thickness skin graft on the buccal mucosa, three buccal mucosal advancement flaps after triangular excision of the mouth corner, and one local buccal mucosal flap. Mouth opening was increased by 6.0 mm, and the intercommissure distance improved by 7.2 mm on average. Follow-up was 9.6 months (range, 5–14 months). Cosmetic assessment was as follows: two patients found the results excellent, three judged it as good.Conclusion Microstomia has several causes. In order to achieve optimal functional recovery and aesthetic improvement it is important to precisely evaluate the etiologic factors and the severity of the impairment and to carefully choose the appropriate surgical method.

Acquired Full-Thickness Nasal Ala Defects: General Principles and Reconstruction Options

The article presents the data of scholarly publications on the general principles and organizational solutions for nasal ala reconstruction of full-thickness defects. The reconstruction of the full-thickness nasal ala defect includes restoration of the external skin and internal covering epithelium, formation of support structures to achieve a stabile shape and position of the alar subunit. With this end in view, plastic material in the form of composite grafts from the auricle is applied, and each tissue layer is formed separately in the region of the defect. The external skin is most often reconstructed with medial cheek cutaneous flaps. The support structures are formed with cartilage autografts. The reconstruction of the internal lining defect is performed with local mucosal or skin flaps, more rarely mucosal or skin grafts. The limiting factors are: risk for ischemic complications, surgical trauma, and secondary surgical correction. The agenda do not only include achievement of acceptable anatomical and functional results but also the quality of perioperative life, shorter time and duration of the surgical intervention and minimum changes in the donor site.

Reduction of post-operative pain after tonsillectomy by a local mucosal flap – a prospective, randomized, controlled clinical trial on 100 adult patients

Background: Tonsillectomy is one of the most frequent operations in otorhinolaryngology being associated with intense post-operative pain and an impairment of swallowing and speech.Aims: To determine whether wound sealing with a local mucosal flap can improve patient rehabilitation.Materials and methods: The study was designed as a prospective, randomized, monocentric, controlled clinical trial including 100 patients. Patients were operated on using either conventional extracapsular tonsillectomy (n = 50) or a modified technique with a local mucosal flap prepared from the posterior surface of the tonsil (n = 50). Number of requested pain medications, local oedema, patient-reported pain level, post-operative haemorrhage, impairment of speech, swallowing and general condition were assessed. The study was registered at the German Clinical Trials Register.Results: The mucosal flap technique significantly reduced post-operative pain [2.94 (intervention group) vs. 4.61 (control group) in an numerical analogue scale, p < .001] and the number of pain medications [6 (intervention group) vs. 1 (control group), p < .001].Conclusions: Wound sealing with a local mucosal flap can reduce post-operative pain in tonsillectomy patients and is recommended whenever anatomically feasible.Significance: This new tonsillectomy technique can help to reduce post-operative pain and thereby improve the patients’ post-operative rehabilitation.

Healing septal perforations by secondary intention using acellular dermis as a bioscaffold.

Several techniques are described in the literature for nasal septal perforation repair. Most of these involve interposition grafts in conjunction with local pedicled mucosal flaps. The following article describes our experience using acellular dermis as a bioscaffold to support the regrowth of nasal septal mucosa by secondary intention. Retrospective chart review of all patients who underwent repair of nasal septal perforations by the senior author using acellular dermis placed between the 2 sides of the perforation and covered with silastic splints to allow for mucosalization. Thirteen patients underwent nasal septal perforation repair using this technique. All perforations repaired were under 2 cm in greatest dimension. Two-thirds of patients had complete closure of the perforation upon initial use of bioscaffolding technique. The remaining third achieved near-total closure with bioscaffolding technique and were able to be completely closed with a single additional procedure. Acellular dermis offers an alternative to most currently described complex flaps. The method can be used in patients with defects less than 2 cm, but initial data suggest caution when using in those with wound healing impediments. This technique is also an excellent choice for patients with multiple small septal perforations.

Staged Double‐Layer Closure of Palatal Defects in 6 Dogs

To report a staged approach that includes selective dental extractions before definitive double-layer hard palate defect closure in dogs. Retrospective case series. Dogs (n = 6) with a palatal defect. Dogs had selective maxillary teeth extractions 4-8 weeks before definitive hard palate defect repair by double-layer local full-thickness mucosal flaps. All palatal defects were considered complex. Complete hard palate closure was achieved after initial attempt in 3 dogs; 2 dogs had revision surgery before complete closure, and in 1 dog, closure failed and further treatment was declined. No complications or long-term consequences were associated with selective dental extractions. Selective dental extractions before definitive surgical repair using mucosal flaps in a double-layer approach is an effective alternative when treating complex hard palate defects in dogs.

Histology of the Oral Mucosa in Patients With BRONJ at III Stage: A Microscopic Study Proves the Unsuitability of Local Mucosal Flaps

BackgroundBisphosphonate Osteonecrosis of the Jaw (BRONJ) is a newly recognized condition reported in patients treated with aminobisphosphonates (BF). BRONJ is defined as the presence of exposed necrotic alveolar bone that does not resolve over a period of 8 weeks in a patient taking bisphosphonates who has not had radiotherapy to the jaw. Treatment protocols have been outlined, but trials and outcomes of treatment and long-term follow-up data are not yet available. In 2004 an expert panel outlined recommendations for the management of bisphosphonate-associated osteonecrosis of the jaws. Through the histological study of the oral mucosa over the bone necrosis and around the osteonecrosis area in 8 patients affected by BRONJ at III stage, the authors highlight the inappropriateness of the local mucosal flaps to cover the losses of substance of the jaw, BF-related.MethodsMucosa tissue was taken from 8 patients, affected by BRONJ, III stage. The samples taken from the mucosa around and over the osteonecrosis area were fixed with formalin and an ematossilina-eosin dichromatic coloring was carried out.ResultsThe samples of mucosa showed pathognomonic signs of cell suffering that prove that in these patients using local mucosa flaps is inappropriate.ConclusionsThe authors suggest that only a well vascularized flap as free flap must be used to cover the osteonecrosis area in patients with BRONJ stage III. Because of the structural instability of the mucosa in patients suffering of osteonecrosis Bf related the local flaps are prone to ulceration and to relapse.

Rotation Flaps after Draf Procedures: A Cadaver Study

Objective: To describe the anatomy and application of local mucosal flaps to reduce cicatricial scarring of the frontal recess after Draf IIB and Draf III procedures. Method: Description and illustration of the surgical technique of 2 local mucosal flaps after Draf IIB and III procedures in a cadaveric model. Results: Two distinct local rotation flaps can be successfully used after Draf IIB and Draf III procedures. 1) Prior to superior middle turbinectomy, a medially based mucosal flap is elevated from the medial aspect of the middle turbinate to the nasal septum. This flap is then placed on the posteromedial raw bone of the frontal recess after the Draf IIB. 2) Bilateral posteriorly based flaps are elevated off of the anterosuperior septum prior to the septectomy in a Draf III procedure. After the drillout is performed, the mucosal flaps are rotated to cover the frontal sinus posterior table. Conclusion: Use of local mucosal flaps to provide primary healing after Draf IIB and Draf III procedures is technically feasible and may decrease the risk of restenosis after frontal sinus surgery.

Pedicled local mucosal flap and autogenous graft for the closure of nasoseptal perforations

Conclusion. The results suggest that the procedure is effective in the repair of nasal septal perforations (10–20 mm in diameter). Therefore, we consider it to be a good alternative for repairing nasal septal perforations. Objective: To introduce and evaluate a technique of pedicled local mucosal flap with the interposition of an autogenous graft in the repair of nasal septal perforations. Methods: Between 2004 and 2008, the clinical notes of 28 patients with nasal septal perforations (10–20 mm in diameter) undergoing the surgery of pedicled local mucosal flap with the interposition of an autogenous graft were reviewed. Results: Complete perforation closure was achieved in 26 cases (92.9%). Two patients had a reperforation, one receiving a second technique and a subsequent successful closure of the perforation; the other case with an asymptomatic perforation did not undergo further surgery. No serious complications were encountered.

Techniques and Results of Urethroplasty for Female Urethral Strictures: Our Experience With 17 Patients

To report our experience with urethroplasty in women with urethral stricture and discuss the therapeutic considerations and outcomes of various flap- and graft-based techniques. A total of 17 patients with mid to distal urethral stricture (urethral caliber <14F, maximal urinary flow rate <12 mL/s, and detrusor pressure >20 cm H(2)O during voiding) underwent urethroplasty from 2004 to 2010. Of the 17 patients, 7 had undergone previous instrumentation and 10 were repaired primarily. The preoperative workup included American Urological Association symptom score assessment, uroflowmetry, voiding cystourethrography, and urethrocystoscopy. Of the 17 patients, 10 received anterior vaginal wall mucosa inlay urethroplasty. Proximally, the dilated urethral mucosa was used in 1 patient. A Martius flap reinforced ventral buccal mucosa graft (BMG) onlay urethroplasty was used in 2 patients with previous synthetic midurethral slings. Two patients with an atrophic vagina received a dorsal BMG onlay. A circular BMG reconstruction was used in 2 patients with severe distal urethral stricture. The preoperative findings were compared with the postoperative data at the last follow-up using the Wilcoxon sign test. With a median follow-up of 24 months (range 6-78), an objective and subjective cure was achieved in 17 (100%) and 15 (88%) patients, respectively. At the last follow-up, the mean maximal urinary flow rate increased from 10.8 ± 3.2 mL/s preoperatively to 28.9 ± 7.4 mL/s (P = .001), and the mean postvoid residual urine volume had decreased from 120 ± 30 mL preoperatively to 30 ± 12 mL (P = .001). The mean American Urological Association score had decreased from 27.1 ± 3.9 preoperatively to 7.1 ± 3.5 postoperatively (P < .0001). Primary urethroplasty can be considered a first-line option for treatment of female urethral strictures. Local mucosal flaps will cure the problem in most situations. BMG offers an excellent alternative when viable local tissue is absent.

Closure of palatal fistula with buccal fat pad flap

Palatal fistula as a complication of palatal surgery is difficult to manage due to the presence of fibrotic and scarred tissue and the absence of local virgin tissue. Recurrence rates are high. To investigate the efficacy of repairing small and medium sized palatal fistulas using the buccal fat pad (BFP), 20 patients (aged 2.5-19 years) with palatal fistula (10-20mm) underwent closure surgery using a pedicled BFP flap. The nasal layer was closed by a local mucosal flap (turn down flap) and the pedicled BFP flap was used for oral lining. Full epithelialization of the BFP layer was observed within 4 weeks in all patients. A 2mm defect in the anterior part of the previous fistula location remained in one case, which spontaneously healed after 2 months; all others closed successfully. Mild pain and cheek swelling occurred in 10 patients, which disappeared within 5 days with no surgical intervention. This study suggests the pedicled BFP flap is a simple and relatively secure method for palatal fistula management. It is recommended for fistulas less than 20mm in length located in the posterior two-thirds of the palate.

Reconstruction of the cranial base following endonasal skull base surgery: Regional tissue flaps

Advances in endoscopic techniques and technology have substantially increased the scope of expanded endonasal skull base surgery. Larger and more complex skull base defects pose a unique challenge for reconstruction. The pedicled nasoseptal flap has become the workhorse for reconstruction and, through its use, the virtues of a vascularized reconstruction are clearly apparent. When local mucosal flaps are unavailable or insufficient for reconstruction, regional flaps may be employed. In this paper, we describe the techniques for three regional vascularized flaps that have been modified for endonasal skull base reconstruction: the transpterygoid temporoparietal fascial flap, the endoscopic pericranial flap, and the modified palatal mucosal flap. These flaps offer a large surface area of tissue supplied by a vascular pedicle that has sufficient reach and arc of rotation to adequately reconstruct portions of the ventral skull base. The specific anatomy, techniques, and technical considerations are discussed in detail to provide a comprehensive approach for skull base reconstruction.