Mucosal Flap Research Articles

The Clinical Efficacy of Silicone Stents for Endoscopic Dacryocystorhinostomy: A Meta-Analysis.

We evaluated the effect of silicone stent use during endoscopic dacryocystorhinostomy on postoperative morbidities in comparison with versus without a silicone stent. Two authors independently searched six databases (PubMed, Embase, Scopus, the Web of Science, the Cochrane library, and Google Scholar) from inception of article collection to July 2017. The analysis included prospective randomized studies that compared intraoperative silicone stent insertion (silicone group) with no application of a silicone stent (control group), in which the outcomes of interest were success rate (lacrimal passage patent check with syringing, symptom relief, or endoscopic confirmation of fluorescein dye from the opening of Hasner’s valve) and morbidities (e.g., postoperative bleeding, rhinostomy closure, granulation tissue, synechia, and eyelid problems) after certain follow-up periods (over 10 weeks). Nine studies involving a total of 587 participants were included. Functional success rates tended to be higher in the silicone group than in the control, but there was no statistically significant difference in success rates (odds ratio, 1.45; 95% confidence interval, 0.77 to 2.73). According to the surgical type such as mucosal removal and mucosal flap surgery, the results from types didn’t demonstrate any significant effect, but the mucosal flap technique seemed to be more beneficial. Regarding postoperative morbidities, although the outcomes of the groups did not present any statistically significant difference, eyelid problems and postoperative bleeding tended to occur more frequently in the silicone group, but rhinostomy closure tended to occur more frequently in the control group. Success and morbidity rates showed no difference between the silicone stent group and control group in the meta-analysis. However, additional analyses revealed that the success rate of endonasal dacryocystorhinostomy using silicone intubation with mucosal flap has shown an improving trend, and morbidities such as granulation and synechia showed decreasing trends compared with the group without silicone intubation.

A mucosal Flap for Periapical Surgery

The function of flap is to raise the soft tissue overlying the surgical site to give the best possible view to the operator and sufficient exposure of the area to be operated on with minimal postoperative complications.The objective of this study is to evaluate a new flap design for exposure of periapical lesion, also to compare it with other common flaps used in periapical surgery.The study include 107 young patients apicectomized for one, two, or three anterior teeth from January2007 to June 2008, age ranged between 18-30 years old, using special case sheet.The flap has given good access to one, two or three apices apicectomized with less postoperative complications including pain, swelling, parasthesia of lip and wound healing.The flap described is an alternative approach to reach the periapical area that may be used to overcome the disadvantages of other flap designs used in periapical surgery.

Revision eDCR using a superior pedicled mucosal flap

ABSTRACTBackground: Endoscopic dacryocystorhinostomies (eDCRs) show patency rates between 81% and 94%. However, dacryocystorhinostomy (DCR) failure and the need for revision remain a significant challenge. One of the principal challenges in revision eDCR is the need to surgically identify the correct osteotomy site and maintain long-term patency in the setting of previously instrumented and potentially scarred tissue. At the same time, the surgeon must assume that the blood supply to the commonly described anterior and posteriorly pedicled flaps has been compromised.Objective: The objective of the study is to describe a novel flap technique for revision eDCR.Methods: The superior based mucosal flap is a novel technique that provides a vascularized mucosa preserving technique in revision eDCR despite previous instrumentation of the lacrimal system. This technique provides wide exposure of the revision osteotomy site while simultaneously allowing a viable mucosal flap to be replaced at the conclusion of the procedure, thereby minimizing bone exposure and cicatricial restenosis.Results: The authors have utilized this technique in 13 procedures with 100% positive identification of the lacrimal sac, a 0% complication rate, and a 100% success rate after a mean follow-up of 26.93 ± 10.33 months (range 6–35 months).Conclusion: The eDCR using the superior pedicled mucosal flap provides excellent exposure of the maxillary bone and the lacrimal sac. This method preserves vascularity of the flap using a superiorly based pedicle which is typically inviolate during both open and endoscopic primary DCR. The mucosal flap can then be replaced, thereby minimizing bone exposure and optimizing patency.

Functional and aesthetic reconstruction of a large upper lip defect using combined three local flaps

Rationale:A significant clinical issue for treating patients with large upper lip defects is how to reconstruct the lip functionally and aesthetically. Traditional methods usually lead to asymmetry of the nasal base, philtrum and the lips.Patient concerns:A 22-year-old lady presented with a large congenital nevus on her upper lip which involved the cutaneous, vermilion, and the philtrum. Secondary deformity caused by previous partial excisions was also identified.Diagnoses:Patient was diagnosed as upper lip nevus with secondary deformity after partial excisions.Interventions:We repaired the large upper lip defect by using combined nasolabial rotation flap and orbicularis oris myocutaneous flap. An additional small piece of mucosal flap was used to lengthen the vermilion.Outcomes:After the surgery, patient with large upper lip defects achieved satisfactory cosmetic and functional repair.Lessons:Reconstruction of the upper lip has been successfully accomplished through the use of combined nasolabial rotation flap, orbicularis oris myocutaneous flap, and a small piece of mucosal flap.

Innovative Use of Insulated Microear Ball Probe Cautery in Creation of Nasal Mucosal Flap in EnDCR.

To study the outcome and complications of endoscopic endonasal dacryocystrhinostomy without stenting. Randomised prospective observational design. Tertiary academic centre. Seventy patients, clinically diagnosed as chronic dacryocystitis with nasolacrimal duct obstruction on the basis of syringing, were enrolled. Endoscopy was done for nasal pathology especially mucosal disease, hypertrophied turbinate, DNS. Seventy-eight eyes were operated with endoscopic-dacryocystorhinostomy along with additional surgeries and periodically followed up on OPD-basis at the end of 1st week, 2nd week, 1st month and 3rd month and evaluated clinically and by syringing (Ophthalmologist) and endoscopy done, wherever required. Insulated microear ball probe cautery was used to create nasal mucosal flap in all cases. Eleven patients underwent septal surgery along with one concha bullosa and one agger nasi removal (p<0.05). Nil intraoperative complications (p<0.05) and single postoperative complication noted (p<0.05). Functional and anatomical patency found to be 100% at the end of 1st week, 98.7% at the end of 2nd week, 93.6% at end of 1st month and 91% at end of 3rd month. Nasal endoscopy showed restenosis in 1 patient at end of 2nd week, 4 patients at end of 1st month, 1 patient at the end of 3rd month along with granulation in 1 patient at the end of 3rd month. Revision surgery was done on 2 patients. Endoscopic dacryocystorhinostomy is safe and successful procedure for chronic dacryocystitis, due to nasolacrimal duct obstruction with less complications without stenting. The associated intranasal pathology, which might be the cause, can be corrected and bilateral dacryocystorhinostomy can be performed in single sitting reducing patient's morbidity and hospital stay. Use of cautery with insulated ball probe for making nasal mucosal flaps gives an precise and excellent blood less field.

Mucosal advancement flap for fistula-in-ano: A single-institution experience

Background and Objective: Mucosal advancement flap (MAF) is a well-described definitive treatment for complex fistula-in-ano, with high healing rates ranging from 37 to 87% for cryptoglandular fistula, but with mild incontinence rates of up to 35%. There is a paucity of Australian data to support the efficacy and complication rates of MAF, nor predictive factors for success. Patients and Methods: This was a retrospective study, with ethical approval granted by St. Vincent's Hospital Melbourne (SVHM) Quality and Risk Unit. Patients who underwent MAF at SVHM and St Vincent's Private Hospital Fitzroy from 2011 to 2015 were included in the study; all data were collected from patient medical records. Results: A total of 65 patients were treated with MAF during the study period. Fistula etiology was cryptoglandular in 82%, anovaginal in 11%, and perianal Crohn's disease in 7% of patients. Overall success rates for MAF were 66% for cryptoglandular fistula, 14% for anovaginal fistula, and 40% for Crohn's fistula. Excluding anovaginal fistulae, the success rate of MAF was 74% for males and 57% for females. MAF performed for an anterior internal opening was associated with a success rate of 65% versus 56% for a posterior internal opening. Postoperative fecal incontinence rate was 6%. Five of the patients with failed MAF underwent a second sphincter-preserving procedure; none of these were successful. Conclusion: This study supports the use of MAF for the treatment of complex fistula-in-ano, with a success rate compatible with existing literature and a low incontinence rate.

Topographic, histological and molecular study of aberrant crypt foci identified in human colon in different clinical groups.

Background/AimsAberrant crypt foci (ACF) are early microscopic lesions of the colonic mucosa, which can be detected by magnified chromoendoscopy. Herein, we have investigated whether ACF identified in different clinical groups can be differentiated based on their characteristics.MethodsMacroscopically unremarkable mucosal flaps were collected from 270 fresh colectomies and divided into 3 clinical groups: colorectal carcinoma (group A), disease controls having known pre-neoplastic potential (group Bc), and disease controls without risk of carcinoma development (group Bn). Topographic and histologic analysis, immunohistochemistry, and molecular studies (high-resolution melt curve analysis, real-time polymerase chain reaction, and Sanger sequencing) were conducted for certain neoplasia-associated markers.ResultsACF were seen in 107 cases, out of which 72 were left colonic ACF and 35 right colonic ACF (67.2% vs. 32.7%, P=0.02). The overall density of left colonic ACF was 0.97/cm, which was greater than the right colonic ACF density of 0.81/cm. Hypercrinia was present in 41 out of 72 left colonic ACF and in 14 out of 35 right colonic ACF (P=0.01). Immunohistochemical expression of p53 was also greater in left colonic ACF than in right colonic ACF (60.5% vs. 38.2%, P=0.03). However, ACF identified among the 3 clinical groups did not show any distinguishing topographic, histological, or genetic changes.ConclusionsLeft colonic ACF appear to be high-risk based on their morphological and prototypic tumor marker signature. ACF identified in different clinical groups do not show significant genotypic or topographic differences. Further detailed genetic studies are required to elucidate them further.

Reconstruction of the Nose by the Forehead Flap and a Modified Mucosal Flap ? A Case Report

Reconstruction of the Nose by the Forehead Flap and a Modified Mucosal Flap ? A Case Report

Impact of Flab Technique Versus Non-Flap Techniques on Endoscopic Dacryocystorhinostomy

Objective: to compare the influence of flap versus non-flap technique on endoscopic dacryocystorhinostomy (EDCR). Patients and Method: A prospective randomized trial in patients with bilateral nasolacrimal duct obstruction, comparing the two techniques to avoid inter-patient variability. We included all patients where bilateral epiphora, excluding unilateral, previously operated or recurrent cases. Results: One hundred patients, fifty females and fifty males with bilateral epiphora due to naso-lacrimal duct obstruction were operated upon by EDCR with or without flap technique. Out of 100 EDCR procedures with flap technique, only 3 had recurrent epiphora with stenosis of the ostium on endoscopic examination and failed fluorescein dye test. In contrast, 4 procedures without flap failed as evident by recurrent epiphora, endoscopic and fluorescein dye test criteria. Conclusion: There is no difference between DCR with flap preservation and flap removal in success rate but the preservation of both lacrimal and mucosal flaps aids in reducing the post-operative granuloma development.

Iatrogenic seeding of skull base chordoma following endoscopic endonasal surgery.

Iatrogenic tumor seeding after open surgery for chordoma has been well described in the literature. The incidence and particularities related to endoscopic endonasal surgery (EES) have not been defined. The authors retrospectively reviewed their experience with EES for clival chordoma, focusing on cases with iatrogenic seeding. The clinical, radiographic, pathological, and molecular characterization data were reviewed. Among 173 EESs performed for clival chordomas at the authors' institution between April 2003 and May 2016, 2 cases complicated by iatrogenic seeding (incidence 1.15%) were identified. The first case was a 10-year-old boy, who presented 21 months after an EES for a multiply recurrent clival chordoma with a recurrence along the left inferior turbinate, distinct from a right petrous apex recurrence. Both appeared as a T2-hypertintense, T1-isointense, and heterogeneously enhancing lesion on MRI. Resection of the inferior turbinate recurrence and debulking of the petrous recurrence were both performed via a purely endoscopic endonasal approach. Unfortunately, the child died 2 years later due progression of disease at the primary site, but with no sign of progression at the seeded site. The second patient was a 79-year-old man with an MRI-incompatible pacemaker who presented 19 months after EES for his clival chordoma with a mass involving the floor of the left nasal cavity that was causing an oro-antral fistula. On CT imaging, this appeared as a homogeneously contrast-enhancing mass eroding the hard palate inferiorly, the nasal septum superiorly, and the nasal process of the maxilla, with extension into the subcutaneous tissue. This was also treated endoscopically (combined transnasal-transoral approach) with resection of the mass, and repair of the fistula by using a palatal and left lateral wall rotational flap. Adjuvant hypofractionated stereotactic CyberKnife radiotherapy was administered using 35 Gy in 5 fractions. No recurrence was appreciated endoscopically or on imaging at the patient's last follow-up, 12 months after this last procedure. In both cases, pathological investigation of the original tumors revealed a fairly aggressive biology with 1p36 deletions, and high Ki-67 levels (10%-15%, and > 20%, respectively). The procedures were performed by a team of right-handed surgeons (otolaryngology and neurosurgery), using a 4-handed technique (in which the endoscope and suction are typically passed through the right nostril, and other instruments are passed through the left nostril without visualization). Although uncommon, iatrogenic seeding occurs during EES for clival chordomas, probably because of decreased visualization during tumor removal combined with mucosal trauma and exposure of subepithelial elements (either inadvertently or because of mucosal flaps). In addition, tumors with more aggressive biology (1p36 deletions, elevated Ki-67, or both) are probably at a higher risk and require increased vigilance on surveillance imaging and endoscopy. Further prospective studies are warranted to evaluate the authors' proposed strategies for decreasing the incidence of iatrogenic seeding after EES for chordomas.

Revisiting lip shave: a solution for disorders of the vermilion border

Actinic keratosis, leukoplakia, carcinoma in situ, and superficially invasive carcinomas of the lower lip are caused mainly by the cumulative effects of exposure of the vermilion of the lower lip to ultraviolet radiation. Current treatments all have limitations: cryosurgery or electrosurgery is suitable to treat only focal lesions; topical chemotherapy, which is an option for diffuse actinic damage, yields unreliable results; and laser treatment fails to rejuvenate the vermilion. However, “lip shave”, which involves full-thickness excision of the damaged vermilion and reconstruction with an advancement labial mucosal flap, will produce a fresh mucosal lining to the vermilion border. We describe our experience of the technique and evaluate the functional and aesthetic outcomes in 20 patients treated between January 2011 and January 2016. The follow-up period ranged from 24 to 60 months. Three-quarters of the patients had dysplasia or superficially invasive malignancy. Resected lesions were about 63mm long, 13.7mm wide, and 3.9mm deep. No patients had recurrence or secondary lesions during follow up, functional disturbance was minimal, and the cosmetic outcome pleasing. Lip shave can efficiently reconstruct the vermilion of the lower lip with minimum deformity.

A new endoscopic technique to close big nasal septal perforations: Prospective evaluation of the double meat hook technique in 19 consecutive cases.

Despite the variety of surgical techniques available to close big symptomatic septum perforations, closure rates of 30 to 70% indicate the difficulty of obtaining a good end result. The double meat hook technique is a new endoscopically assisted technique that delivers excellent visualization and control of mucosal flap elevation, extension and suturing. Mucosa from the nasal floor, lateral nasal wall and inferior turbinate bone are valuable donor site extensions. There is no need for additional incisions into the nasal septal mucosa in order to perform a tension-free closure. Preservation of the structural integrity and blood supply of the mucosal flaps, possibly contributes to a high closure rate and delivers a physiological result. This article is protected by copyright. All rights reserved.

Low complication rate of sellar reconstruction by artificial dura mater during endoscopic endonasal transsphenoidal surgery.

To evaluate effect of sellar reconstruction during pituitary adenoma resection surgery by the endoscopic endonasal transsphenoidal approach using artificial cerebral dura mater patch.This was a retrospective study of 1281 patients who underwent endoscopic transsphenoidal resection for the treatment of pituitary adenomas between December 2006 and May 2014 at the Neurosurgery Department of the People's Liberation Army General Hospital. The patients were classified into 4 grades according to intraoperative cerebrospinal fluid (CSF) leakage site. All patients were followed up for 3 months by telephone and outpatient visits.One thousand seventy three (83.7%) patients underwent sellar reconstruction using artificial dura matter patched outside the sellar region (method A), 106 (8.3%) using artificial dura matter patched inside the sellar region (method B), and 102 (8.0%) using artificial dura matter and a mucosal flap (method C). Method A was used for grade 0–1 leakage, method B for grade 1 to 2 leakage, and method C for grade 2 to 3 leakage. During the 3-month follow-up, postoperative CSF leakage was observed in 7 patients (0.6%): 2 among patients who underwent method B (1.9%) and 5 among those who underwent method C (4.9%). Meningitis was diagnosed in 13 patients (1.0%): 2 among patients who underwent method A (0.2%), 4 among those who underwent method B (3.8%), and 7 among those who underwent method C (6.7%).Compared with other reconstruction methods, sellar reconstruction surgery that only use artificial dura mater as repair material had a low rate of complications.

Correction of vermilion lip retraction after mucosal advancement flap: A countertraction technique

Correction of vermilion lip retraction after mucosal advancement flap: A countertraction technique

A novel technique for unilateral supraglottoplasty

ObjectivesTraditional supraglottoplasty for pediatric laryngomalacia is most commonly conducted with either CO2 laser or cold steel instruments. While the procedure enjoys high success rates, serious complications such as excessive bleeding, supraglottic stenosis and aspiration can occur. Unilateral coblation supraglottoplasty may reduce this risk, but data on respiratory and swallowing outcomes are lacking. This study reports our experiences with unilateral coblation supraglottoplasty. MethodsPediatric patients with severe congenital laryngomalacia who underwent unilateral supraglottoplasty at a single institution from 2013 to 2016 were retrospectively reviewed. Bipolar radiofrequency ablation (Coblation) was utilized with partial arytenoidectomy, aryepiglottoplasty, and advancement of mucosal flaps. Outcome measures included apnea-hypopnea index (AHI), weight-by-age percentile, and decannulation rate. ResultsTwelve patients were included with an average age of 13.1 months (range 2–28 months). In patients without tracheostomy, 88% had complete resolution of respiratory symptoms, while the remainder had significant improvement. In patients without gastrostomy tubes, there was an average increase in weight-age percentile of 6.1, 7.8, and 15.3 points at 1, 3, and 6 months postoperatively, respectively. Three patients had complete polysomnography data with a mean preoperative AHI of 19.3 and postoperative AHI of 4.0. Three of four patients with tracheostomy have been decannulated at a mean follow-up of 1.5 years. There were no early or late postoperative complications and no revision supraglottoplasty. ConclusionUnilateral supraglottoplasty with bipolar radiofrequency ablation can improve respiratory symptoms and decrease OSA severity in severe congenital laryngomalacia. This technique is safe and can lead to substantial improvement in AHI in patients with OSA.

Buccal mucosal urethroplasty, first experience in the Samara region

The incidence of urethral strictures in the structure of genitourinary diseases is about 6%. Treatment effectiveness, according to the literature, accounts for only 30%. The article describes the authors’ early experience of urethroplasty with free flaps of oral mucosa. Similar operations were performed for the first time in the Samara region. The stages of the surgery are described, images of surgical stages and pre- and post-operative urethrography results are presented. From the oral cavity a full-thickness mucosal flap 4×1.5 cm in size was taken. Wounds in the oral cavity were sutured, whereby uniform epithelialization without forming rough scars occurred. Through perineal access bulbar urethra with cicatricial changes was approached and mobilized. Buccal flaps were separated from underlying fatty tissue and sequentially fixed to the cavernous bodies with the separate sutures. Dorsal wall of the mobilized urethra was incised along the stricture. Bladder was drained through silicone catheter 14 Ch, above which the edges of incised urethra were sutured with the edges of transplanted mucosa. Surgical wound was sutured in layers tightly. In the late postoperative period, patients underwent urethrocopy and uroflowmetry. Good functional results were achieved.

A Novel Use of a Novel Drug: Preoperative Nasal Preparation with Dexmedetomidine for Transnasal Transsphenoidal Neurosurgery Approach in Skull Base Neurosurgery

Introduction Transnasal transsphenoidal (TNTS) approach is preferred for surgical excision of the pituitary gland. Despite its numerous merits, the TNTS approach creates wide fluctuations in hemodynamic parameters that are attributed to the routine application of adrenaline-soaked nasal packing and the intense noxious stimulus during the surgery. Aims To evaluate the effect of dexmedetomidine for preoperative nasal passage preparation on the surgical field visualization and hemodynamic profile of patients during TNTS surgery. Material and Methods Cotton strips soaked in dexmedetomidine were used for nasal preparation. The primary outcomes studied were the quality of surgical field visualization through the endoscope and the amount of bleeding that occurred while raising the nasal mucosal flap. The secondary outcomes assessed were the intraoperative anesthetic and analgesic requirement and the hemodynamic profile. Statistical Analysis Data from the study were summarized as mean and SD. Associations were tested using chi-square test for nonparametric data and for continuous variables ANOVA for repeated measures. A p-value &lt; 0.05 was considered as statistically significant and &lt; 0.01 as highly significant. SPSS 17.0 was used for analysis. Results Seventeen (85%) patients had a Formmer's score of 1, which was an excellent surgical field quality. Two (10%) patients had a Formmer's score of 2, and one (5%) had a Formmer's score of 3. There were no statistically significant variations in heart rate and blood pressure with reduced anesthetic requirement. Conclusion Intranasal dexmedetomidine provides good surgical field conditions with the added advantage of lesser hemodynamic fluctuations.

Anatomical Reconstruction of the Nasal Floor in Complete Unilateral Cleft Lip Repair.

Numerous methods exist for repairing unilateral cleft lips and mainly focus on cutaneous design to achieve sufficient rotation of the medial (M) cleft lip and produce a natural Cupid's bow and philtrum. However, precise nasal floor reconstruction has not been described in detail. This is the first study to introduce a technique for repairing complete unilateral cleft lips with a focus on nasal floor reconstruction. In our technique, "Straight-Line Advanced Release Technique (StART)," the nasal floor is considered a 3-dimensional cuboid structure; the M mucosal and lateral (L) mucosal flaps constituted the posterior surface. The M flap became the roof of the orbicularis oris muscle sling and the posterior side of the nasal lining. The B flap met the L lip flap at the superior border of the M flap, and together they formed the roof and anterior surface. The B flap also formed a transitional zone connecting the columella and nasal floor. Seventy-two patients with complete unilateral cleft lip were treated from 2003 to 2015. The difference in the height of the nostril sills between the cleft and non-cleft sides was not significantly different from that in control patients (P = 0.472) 1 year postoperatively. Twenty operations for secondary deformities were performed: 8 for nose deformities not involving the nasal floor. The transverse scar at the alar base was concealed within the nostril. Nasal floor reconstruction is important in complete unilateral cleft lip repair. Our technique provides a naturally shaped, symmetrical nasal floor without conspicuous scarring.

The evolution of oculoplastic operations

SummaryAlthough oculoplastic surgery has only recently been recognized as a subspecialty, the early origins of the interrelationship between plastic surgery and ophthalmology, trace back to the 22th century B.C. Minor eyelid operations performed by Babylonian and Assyrian physicians as well as eyebrow stitching descriptions, contained in the Egyptian Papyrus, serve as the earliest surgical attempts at oculoplastic surgery. Other ancient civilizations also provided accurate descriptions of a number of eyelid diseases, including their surgical treatment. During the Greco‐Roman period, several local flaps, e.g. the double‐pedicled and the V‐Y advancement flap, were first described. Byzantine physicians compiled, standardized and enriched the medical knowledge of their Greco‐Roman predecessors, contributing with the surgical treatment of trichiasis, lagophthalmos, ectropion, hydatids, epicanthus, pterygia, lacrimal fistulae and eyelid adhesions. The following centuries, a variety of surgical techniques were developed. Thus, modern oculoplastic surgeons, have incorporated numerous reconstructive procedures into their practice, ranging from simple local flaps to complicated mucosal or composite flaps and selective microvascular procedures.

Draf III frontal sinus surgery: "How I do it".

The Draf III approach to the frontal sinus can be used during revision endoscopic sinus surgery for chronic rhinosinusitis and to provide access for tumor resection, mucoceles, and repair of cerebrospinal fluid leaks. To describe a simple and safe way to perform a Draf III approach by using the "outside-in" approach. By using a 0° endoscope and a single 15°, 5-mm, coarse diamond burr, the main steps of the procedure are the following: (1) elevation of the mucosal flaps and creation of the septal window, (2) drilling out the frontal beak, (3) creation of neo-ostium and removal of the interfrontal septum, (4) joining the neo-ostium with the frontal recesses, (5) smoothing off the cavity and lowering of the "frontal T," and (6) use of mucosal flaps and grafts to cover exposed bone. This approach is a quick and easy way to perform a Draf III, and reduces operative time and minimizes complications.