Releasing Incisions Research Articles

Impiego di osso bovino deproteinizzato granulare negli incrementi orizzontali: presentazione di una tecnica non convenzionale

ObjectivesTo assess the efficacy of a non-conventional technique of bone augmentation of an atrophic ridge for subsequent implant positioning. The method, easy to perform and with few complications, uses the periosteum in place of a membrane in combination with a biomaterial. Materials and methodsA patient with a ridge bone defect was treated with a regenerative technique that consists in a muco-periosteal flap with only a crestal incision – without release incisions – in order to preserve the integrity of the periosteum. After performing some drill holes in the cortical bone, granules of heterologous bovine bone were packed over the defect without any membrane. The flap was repositioned over the graft with passive sutures and after eight months the implants were positioned. After 21 months from the graft, a biopsy was performed in order to assess the microscopic features of the regenerated bone. ResultsThe histological findings showed dense, mature, new regenerated bone with lamellar structure. Residual granules of the biomaterial appeared to be integrated in the new bone without any inflammatory reaction. ConclusionsWith the limits of the single investigation, this simplified technique seems to be an alternative method to consider in non-collaborating patients or in front of operative clinical problems. Until now, the association of biomaterials and membranes is the gold standard in bone regeneration techniques for implant therapy.

Ankle dorsiflexion postburn scar contractures: Anatomy and reconstructive techniques

BackgroundPostburn ankle scar contractures cause functional limitations of all lower extremities and create a serious cosmetic defect, not allowing patients to use normal foot wear, and, therefore, needing surgical reconstruction. The anatomic features of ankle dorsiflexion contractures and their treatment have been covered in the literature far less than other joint contractures, and their treatment is still a challenge for many surgeons. A common treatment method is incisional release of the contracture and defect resurfacing with skin graft. Rarely, distally based sural or free flaps and Ilizarov fixator are used. MethodsAnatomy of postburn ankle scar contractures in 55 patients was studied and contractures were surgically treated using a specific approach and technique. Follow-up results were observed from 6months to 16years. ResultsAccording to the anatomic features, dorsiflexion scar contractures were divided into three types: edge, medial, and total. Edge contractures were caused by burns and scars located on the lateral or medial ankle surface and were characterized by the presence of the fold along the anterior edge ankle; the skin of the anterior ankle surface was not injured. Medial contractures were caused by scars located on the anterior ankle surface and were characterized by the presence of the fold along the medial ankle line. Total contractures were caused by scars tightly surrounding the ankle. In fold's sheets of edge and medial contractures there is a trapeze-shaped surface deficit in length (cause of contracture) and a surface surplus in width which allows contracture release with local trapezoid flaps. For total contractures, wide scar excision and skin grafting were indicated. ConclusionThree anatomic types of ankle dorsiflexion scar contractures were identified: edge, medial, and total. An anatomically justified technique for edge and medial contractures is trapeze-flap plasty; total contractures are effectively eliminated with scar excision and skin grafting.

Orthodromic Temporalis Tendon Transfer

Objectives To define (1) at-risk structures during the orthodromic temporalis tendon transfer and (2) achievable tendon length without temporal releasing incisions or perioral lengthening materials...

Comparison of Longitudinal Open Incision and Two-Incision Techniques for Carpal Tunnel Release

Comparison of Longitudinal Open Incision and Two-Incision Techniques for Carpal Tunnel Release

SHORT-TERM RESULTS OF ENDOSCOPIC (OKUTSU METHOD) VERSUS PALMAR INCISION OPEN CARPAL TUNNEL RELEASE: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

The surgical techniques widely used in Japan for idiopathic carpal tunnel syndrome (CTS) are the Okutsu method of endoscopic carpal tunnel release (ECTR) and palmar incision for open carpal tunnel release (OCTR). However, no prospective randomized controlled trials (RCTs) have compared treatment outcomes between these two procedures. This RCT compared short-term outcomes between ECTR and OCTR for CTS. Subjects were 101 hands (79 patients) treated in the department. ECTR was performed on 51 hands (40 patients), and OCTR was performed on 50 hands (39 patients). For assessment items, the following patient-based outcomes were evaluated: 1) changes in subjective symptoms; and 2) impairment in activities of daily living. The following items were also evaluated by physicians: 3) abductor pollicis brevis-distal latency (APB-DL); 4) sensation; and 5) muscle strength. All these assessments were made in postoperative weeks 4 and 12. Recovery of muscle strength at postoperative week 4 was significantly better with ECTR (p< 0.05), but no significant differences were identified between groups in any of the other items. The ECTR group showed transient postoperative exacerbation of subjective symptoms in two hands (4%) and of APB-DL in three hands (6%). Comparison of hands with improved and exacerbated postoperative APB-DL in the ECTR group revealed significantly greater preoperative electrophysiological severity in exacerbated hands (p< 0.05). The cause of postoperative exacerbation with ECTR was considered to be transient nerve dysfunction resulting from the unique aspects of the ECTR procedure. Compared with OCTR, ECTR offers superior recovery of muscle strength in the early postoperative period. At the same time, ECTR may carry a risk of transient nerve dysfunction in the early postoperative period. Caution must therefore be exercised when using ECTR for patients with severe electrophysiological findings.

Inverted and Impacted Maxillary Third Molar: Removal by Lateral Transposition Method

ABSTRACT Background Third molars are one of the most commonly impacted teeth in the oral cavity. But in very rare cases, the impacted molars can be inverted as well. In this case, the patient presented with an inverted and impacted left maxillary third molar. The aim of the operating surgeon was to execute the procedure in the least hazardous manner, to avoid any surgical complications. Methods The surgical extraction of the tooth by lateral transposition method was carried out rather than the classical method owing to the inverted position of the impacted tooth. The surgery was carried out under local anesthesia. An incision was made at the crest of the ridge with an anterior releasing incision. Bone overlying the impacted molar was removed following which the tooth was luxated and laterally transposed. The socket was thoroughly irrigated and closure was done by simple interrupted suture, using 3-0 mersilk. Results The impacted and inverted maxillary third molar was successfully removed by lateral transposition method without any complications. Conclusion The impacted and inverted maxillary third molars are not commonly encountered in dental practice. Subsequently, their removal can be a challenging job on the part of an oral surgeon. The surgeon should preoperatively weigh carefully the associated risk factors and explain them thoroughly to the patient. How to cite this article Chhabra S, Chhabra N, Dhillon G. Inverted and Impacted Maxillary Third Molar: Removal by Lateral Transposition Method. Int J Exper Dent Sci 2012;1(1):26-29.

Orthodromic Temporalis Tendon Transfer

To define (1) at-risk structures during the orthodromic temporalis tendon transfer and (2) achievable tendon length without temporal releasing incisions or perioral lengthening materials. Ten fresh cadavers provided 20 hemifaces for dissection. Measurements and photographic documentation were used to examine the parotid duct, masseteric artery, inferior alveolar nerve, internal maxillary artery, and mobilized tendon relative to adjacent landmarks. The parotid duct was found in a reproducible region posterior to the melolabial crease and inferior to a parotid duct reference line. The masseteric artery was found posterior to the posterior-most attachment of the tendon at its exit from the sigmoid notch (mean, 14.5 mm). The inferior alveolar nerve was found posterior to the anterior edge of the ascending ramus (mean, 18.3 mm). The internal maxillary artery coursed superiorly from posterior to anterior along the medial mandible near the coronoidectomy site. The tendon reached beyond the melolabial crease in 17 of 20 hemifaces (85%). The parotid duct reference line and the melolabial crease allow estimation of the parotid duct location. Anatomical relationships between the tendon, parotid duct, neurovasculature, and anatomical landmarks underscore the importance of deliberate soft-tissue retraction and subperiostial elevation to minimize injury. The tendon alone usually provides adequate length for orthodromic suspension.

Use of commercially available foam pipe insulation as a protective device for wounds over the elbow joint area in five dogs

4 large-breed dogs were referred because of nonhealing skin wounds involving the elbow joint area of several weeks to months in duration. One additional large-breed dog was evaluated because of a draining abscess with overlying skin necrosis. Previous attempts at closing each wound over the elbow joint area had been unsuccessful. At the time of hospital admission, open wounds had variable degrees of bacterial contamination and infection. Open wounds over the elbow joint area were closed by use of bipedicle advancement flaps or direct suture apposition of opposing sides of the wound. Lengths of pipe insulation were applied to the forelimb in a fashion to prevent contact pressure to the olecranon for a prolonged period (4 to 13 weeks) after surgery. All wounds healed completely. Release incisions (donor areas) healed by second intention within 3 weeks after surgery. One dog developed periostitis of the olecranon, which responded to antimicrobial administration. A second dog developed a skin bacterial infection below the surgical area that was markedly resistant to antimicrobials. The layered application of commercially available foam pipe insulation provided a simple and economical protective device after closure of problematic skin wounds involving the elbow joint area. Prolonged protection of the olecranon area helped to assure healing was complete and skin coverage was sufficiently stable to reduce the risk of reinjury after removal of the device. Each patient was able to use the involved forelimb during the treatment period. Paired bipedicle advancement flaps (release incisions) were particularly useful for closing small to moderate defects overlying the olecranon in which simple apposition was not feasible.

Orthodromic Temporalis Tendon Transfer: An Anatomic Study

Objective: 1) Understand the relationship of anatomic structures at risk for injury during the transfacial orthodromic temporalis tendon transfer procedure (OTTT) for facial reanimation. 2) Define the anatomic limitations of the OTTT without temporal releasing incisions of the muscle origin or perioral lengthening materials. Method: Ten fresh cadavers were used to perform 20 hemi-face dissections. Detailed measurements and photographic documentation examined the parotid duct (PD), masseteric artery (MA), inferior alveolar nerve (IAN), and internal maxillary artery (IMA) relative to surgical landmarks. The perioral reach of the mobilized temporalis tendon was measured and photographically documented. Results: Measurements revealed a consistent relationship between the PD and a reproducible reference line. The PD was located within the superior dissection field in all dissections. The IAN was consistently located over a centimeter from the TT insertion on the medial mandible and from the anterior ascending ramus. The MA consistently coursed within millimeters of the most inferior portion of the sigmoid notch within the substance of the masseter muscle. The IMA consistently coursed superiorly from posterior to anterior just medial to the mandible. All tendons (100%) reached beyond the melolabial crease to the perioral musculature for orthodromic resuspension. Conclusion: Reproducible PD-reference line measurements allow for pre-incision PD localization. Consistent relationships between the tendon, PD, neurovascular structures, and bony landmarks underscore that deliberate soft tissue retraction and subperiostial elevation minimizes injury risk. The mobilized tendon appears to achieve adequate length for resuspension without temporal releasing incisions or perioral lengthening materials.

Immediate Postextraction Implant Placement Using Plasma Rich in Growth Factors Technology in Maxillary Premolar Region: A New Strategy for Soft Tissue Management

Achieving an excellent aesthetic outcome in postextraction dental implant placement in the anterior maxilla is a challenging procedure for clinicians. In fact, there is an increased risk for soft tissue recession at the facial aspect which may require supplementary connective tissue grafts to accomplish the final aesthetic result. The aim of this case report is to describe a regenerative technique using autologous plasma rich in growth factors fibrin plug for preservation of soft tissue architecture around an implant immediately placed into an extraction site in the anterior maxilla. Such a procedure allowed for guided bone regeneration without the need for vertical releasing incisions and primary healing, thus showing a pleasant gingival contour at the facial aspect after a single stage surgery. Integrating this technique into common practice could provide important benefits for the patients regarding aesthetics, without any risk of infection or transmission of diseases.

Analysis of Flap Tension in Surgical Rejuvenation of the Midface

To determine the flap tension present for 2 different surgical approaches for midface lifts and whether a gingivobuccal incision for release of the midface periosteum will diminish the resultant load on the midface flap. Cadaver study. Anatomy laboratory at the University of Florida. Twelve fresh-frozen cadaver heads are subjected to a transblepharoplasty (TB) approach on one side of the cadaver head while a transtemporal (TT) approach is performed on the contralateral side. The tension (grams) generated by moving the midface flap a distance of 1.03 cm is recorded by a digital load cell. A gingivobuccal incision is made on each side to allow transoral periosteal release (TOPR) of the midface flap, and the experiment is repeated. Three trials are performed for each operation, and the average load is calculated. A paired t test is applied. The tension resulting from the TT approach (172 g) was not found to be significantly different from that of the TB approach (179 g; P = .75). Significant differences in the resultant tension were not appreciated when comparing standard techniques to TT with TOPR (141.5 g; P = .27) or for TB with TOPR (164.1 g; P = .45). An experimental method is described for determining flap tension in facial rejuvenation surgery. No significant difference is found between flap tensions generated in the TB and TT approaches to the midface.

Comparison of Longitudinal Open Incision and Two-Incision Techniques for Carpal Tunnel Release

Comparison of Longitudinal Open Incision and Two-Incision Techniques for Carpal Tunnel Release

Large myelomeningocele repair

ABSTRACT Background: Wound closure is accomplished in most cases of myelomeningocele (MMC) by undermining of the skin edges surrounding the defect. However, large defects cannot be closed reliably by this simple technique. Due to the technical challenge associated with large MMC, surgeons have devised different methods for repairing large defects. In this paper, we report our experience of managing large defects, which we believe bears a direct relationship to decrease the incidence of wound complications. Materials and Methods: Forty children with large MMCs underwent surgical repair and represent our experience. We recommend using all hairy skin around the defect as a way to decrease the tension on the edges of the wound and the possible subsequent necrosis. It is our experience that vertical incision on one or two flanks parallel to the midline can decrease the tension of the wound. Moreover, ventriculo-peritoneal shunting for children who developed hydrocephalus was performed simultaneously, which constitutes another recommendation for preventing fluid collection and build up of pressure on the wound. Results: Patients in this study were in the age range of 2 days to 8 years. The most common location of MMC was in the thoracolumbar area. All but four patients had severe weakness in lower extremities. We used as much hairy skin around the MMC sac as possible in all cases. Vertical incisions on one or both flanks and simultaneous shunt procedure were performed in 36 patients. We treated children with large MMC defects with acceptable tension-free closure. Nonetheless, three patients developed superficial skin infection and partial wound dehiscence, and they were managed conservatively. Conclusions: We recommend using all hairy skin around the MMC defect for closure of large defects. In cases that were expected to be at a higher risk to develop dehiscence release incisions on one or two flanks towards the fascia were found to be useful. Simultaneous ventriculo-peritoneal shunting is also recommended in this cohort of patients, according to our experience. These recommendations neither prolong the time of surgery nor increase the cost, but facilitate a successful closure.

Large myelomeningocele repair

Background:Wound closure is accomplished in most cases of myelomeningocele (MMC) by undermining of the skin edges surrounding the defect. However, large defects cannot be closed reliably by this simple technique. Due to the technical challenge associated with large MMC, surgeons have devised different methods for repairing large defects. In this paper, we report our experience of managing large defects, which we believe bears a direct relationship to decrease the incidence of wound complications.Materials and Methods:Forty children with large MMCs underwent surgical repair and represent our experience. We recommend using all hairy skin around the defect as a way to decrease the tension on the edges of the wound and the possible subsequent necrosis. It is our experience that vertical incision on one or two flanks parallel to the midline can decrease the tension of the wound. Moreover, ventriculo-peritoneal shunting for children who developed hydrocephalus was performed simultaneously, which constitutes another recommendation for preventing fluid collection and build up of pressure on the wound.Results:Patients in this study were in the age range of 2 days to 8 years. The most common location of MMC was in the thoracolumbar area. All but four patients had severe weakness in lower extremities. We used as much hairy skin around the MMC sac as possible in all cases. Vertical incisions on one or both flanks and simultaneous shunt procedure were performed in 36 patients. We treated children with large MMC defects with acceptable tension-free closure. Nonetheless, three patients developed superficial skin infection and partial wound dehiscence, and they were managed conservatively.Conclusions:We recommend using all hairy skin around the MMC defect for closure of large defects. In cases that were expected to be at a higher risk to develop dehiscence release incisions on one or two flanks towards the fascia were found to be useful. Simultaneous ventriculo-peritoneal shunting is also recommended in this cohort of patients, according to our experience. These recommendations neither prolong the time of surgery nor increase the cost, but facilitate a successful closure.

Contracture related airway obstruction (CRAO) treated successfully with incisional release

Objective: To describe the delayed airway obstruction that can result from anterior cervical burns and report a case of successful decannulation following incisional release and full-thickness skin grafting (FTSG). Methods: Case report from a tertiary care academic children's hospital. Results: Direct laryngoscopy demonstrates a significant improvement in the upper airway immediately following an anterior cervical incisional release. The patient was then able to be decannulated on postoperative day 10. Conclusions: Cervical contracture is an important consideration in children with airway obstruction following burns to the upper chest, anterior neck and face, and may be treated successfully with incisional release and FTSG.

Comparison of Longitudinal Open Incision and Two-Incision Techniques for Carpal Tunnel Release

This study analyzes the long-term postoperative symptoms and functional outcomes of patients who underwent either traditional open (single-incision) or 2-incision carpal tunnel release (CTR). Because 2-incision CTR preserves the superficial nerves and subcutaneous tissue between the thenar and hypothenar eminences, it may account for fewer postoperative symptoms and improved functional recovery. A retrospective chart review identified patients who underwent either open or 2-incision CTR for isolated carpal tunnel syndrome between 2005 and 2008 by a single surgeon. Patients with a history of hand trauma or confounding comorbidities were excluded. We mailed a Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire and a Brigham and Women's Carpal Tunnel Questionnaire (BWCTQ) to all eligible participants. Data from the completed questionnaires were analyzed using independent t-tests and Pearson's correlation. Significance was set at p = .05. A total of 82 patients (106 hands; 27 men and 55 women; mean age, 60.5 y) were eligible to participate. Of these, 51 patients (63 hands; 20 men and 31 women; mean age, 61.1 y) responded (62% response rate). The mean duration of follow-up was 22 months (range, 12-37 mo; SD 7.3 mo). The 2-incision group mean BWCTQ Symptom Severity Scale score (1.13, SD 0.25) was significantly lower than the open group mean Symptom Severity Scale score (1.54, SD 0.70, p = .001). The 2-incision group mean BWCTQ Functional Status Scale score (1.24, SD 0.51) was significantly lower than the open group mean Functional Status Scale score (1.71, SD 0.76, p = .008). The 2-incision group mean DASH score (5.10, SD 12.03) was significantly lower than the open group mean DASH score (16.28, SD 19.98, p = .01). Patients treated with 2-incision CTR reported statistically significantly less severe long-term postoperative symptoms and improved functional status compared with patients treated with traditional open CTR. Future prospective studies with objective measures are needed to further investigate the difference in outcomes found between these 2 CTR techniques. Therapeutic III.

Tragal cartilage augmentation in repair of cleft palate, a new technique and its clinical implications

Background Cleft palate is one of the most common congenital anomalies of the head and neck worldwide. In addition to the evident feeding and growth problems, patients are involved with and suffer from speech, hearing and dental problems. Many surgical techniques and modifications have been advocated to improve functional outcome and aesthetic results, aiming at normal speech, minimizing growth disturbances, and establishing a competent velopharyngeal sphincter. Despite the variety of techniques described for repair of the clefts, there is still a relatively high incidence of postoperative fistula reaching up to 35%. This is mainly related to type and degree of the defect, and type of surgical repair. Objectives To evaluate the efficacy of placement of tragal cartilage free graft between the oral and nasal mucosal layers of the neo-palate in improving success rates, and anatomical and functional outcomes in repair of cleft palate with reduction of the extent of dissection. Patients and methods Fourteen patients were managed by our technique, only in large cases minimal von Langenbeck lateral release incisions were made. In all cases a tragal cartilage graft was interpositioned and fixed to the muscle layer of the neo-palate, 2–3 extramucosal trans-muscle sutures were placed for 3–4 weeks if needed, and the patients were followed up for a minimum of 12 months during which functional and anatomical assessments were done. Results Results, including both anatomical and functional outcomes, were favorable with no gross failures, permanent significant fistula formations (one case with minor non-significant fistula), nor donor site co morbidities. Conclusion The use of tragal cartilage free graft to augment the area at the junction between the hard and soft palate appears to be a safe and effective method in repair of cleft palate that reduces the incidence of postoperative palatal fistulae, without donor site comorbidities.

Periosteal Releasing Incision for Successful Coverage of Augmented Sites. A Technical Note

The periosteal releasing incision (PRI) is very common in intraoral surgical procedures, especially when flap advancement is indicated, that is, when vertical or horizontal augmentations take place. This technical note describes the surgical skills for sufficient flap advancement. Complications due to improper PRI are also discussed.

Coronally Advanced Flap With and Without Vertical Releasing Incisions for the Treatment of Multiple Gingival Recessions: A Comparative Controlled Randomized Clinical Trial

Vertical releasing incisions might damage the blood supply to the flap and result in unesthetic visible white scars. The aim of the present study was to compare root coverage and esthetic outcomes of the coronally advanced flap (CAF) with and without vertical releasing incisions in the treatment of multiple gingival recessions. Thirty-two systemically and periodontally healthy subjects with esthetic complaints due to the exposure of Miller Class I and II multiple (at least two) gingival recession defects (> or =1 mm) affecting adjacent teeth of the same quadrant of the upper jaw were enrolled in the study. Sixteen patients (with 45 gingival recessions) were randomly assigned to the control group, and the other 16 patients (with 47 recession defects) were assigned to the test group. All recessions were treated with a CAF; vertical releasing incisions were performed in the control group, whereas an envelope-type flap was used in the test group. The patient's postoperative morbidity was assessed 1 week after the surgery, whereas the esthetic evaluation, made by the patient and independent periodontist, and the clinical evaluation were made 1 year later. Surgical time was significantly shorter in the envelope-type CAF group. No statistically significant difference was demonstrated between the two groups in terms of recession reduction and clinical attachment level gain. A statistically greater probability of complete root coverage (adjusted odds ratio, 3.76; 95% confidence interval: 0.92 to 15.33; P <0.05) and a greater increase in buccal keratinized tissue height were observed with the envelope type of CAF. Patient satisfaction with esthetics was very high in both treatment groups, with no statistically significant differences between them. A better postoperative course and better results in the esthetic evaluation made by an independent periodontist were demonstrated in patients treated with the envelope type of CAF. Both CAF techniques were effective in reducing recession depth. The envelope type of CAF was associated with an increased probability of achieving complete root coverage and with a better postoperative course. Keloid formation along the vertical releasing incisions was responsible for the worst esthetic evaluation made by an independent expert periodontist.

Improved Non-Coupled Prosthetic Motility Utilizing Motility-Enhancing Fornix Sutures

Purpose: To evaluate the surgical technique and the motility of non-coupled ocular implant and prosthesis complex, utilizing fornix sutures, by examining the outcomes following evisceration surgery. Materials and Methods: Forty patients with atrophic, phthyiscal, or staphylomatous globes underwent evisceration using the scleral overlapping technique with a transequatorial release incision. All the patients were implanted with high-density porous polyethylene implants. Twenty patients underwent evisceration utilizing fornix sutures. The remaining 20 patients underwent a conventional described evisceration technique. Care was taken that no conjunctival shortening was present. Follow-up was for three months. The patients were all fitted by a non-coupled ocular prosthesis at one month and follow-up continued as usual. Results: All cases showed functional improvement with an average increase of motility measurements when utilizing the motility-enhancing fornix sutures in comparison to the described conventional evisceration technique. Motility was measured by evaluating horizontal and vertical excursions. Results were documented up to three months postoperatively. Apart from a late postoperative exposure developing in one case, no cases of additional infection, extrusion, or granuloma formation were encountered. Conclusion: The non-coupled prosthetic motility utilizing motility enhancing sutures was more predictable with superior motility effect over the conventional evisceration technique. However, a longer follow-up and perhaps a larger number of cases may be needed to provide additional support to the findings of this study.