Rotation Advancement Research Articles

The clinical application of lateral chest flap transfer combined with relay skin flap transfer to repair soft tissue defects of the chest wall after tumor resection.

BackgroundAfter thoracic tumor resection, there is often a large area of soft tissue defect left, even with exposed ribs and sternum, which needs to be repaired by skin flap transplantation. This study aims to introduce lateral thoracic flaps combined with local flaps to repair the soft tissue defect of the chest wall after the repair of malignant tumors, and try to retain the latissimus dorsi myocutaneous flap as a spare repair myocutaneous flap to avoid subsequent tumor recurrence and lack of local flaps for supply body source.MethodsA total of 26 patients with chest wall soft tissue defect with or without exposed rib and sternum after tumor resection at presentation from January 2017 to October 2021 were included in this study. None of the patients required breast reconstruction. Patients ranged in age from 34 to 56 years old. The above patients were treated with lateral thoracic flaps combined with local rotational advancement flaps to repair chest wall soft tissue defects. The postoperative wound healing, scar hyperplasia and recurrence of the patients were followed up.ResultsAmong the patients in this study, 25 incisions healed by primary incision, 1 incision was delayed, and healed after 10 days of dressing change. Postoperatively, the incisions of the patients were all intact, and there were no complications such as skin necrosis and infection. All patients were followed up for 6–18 months, and the incision healed well without complications such as skin necrosis and infection. Of the patients, 2 males developed dermatofibrosarcoma carina recurrence 6 and 10 months after surgery, respectively. After extensive excision, an ipsilateral latissimus dorsi myocutaneous flap was used to repair the defect. The Vancouver scar scale was used to evaluate the hyperplasia of all incisions at 6 months postoperatively. The mean score was 5.92±1.6.ConclusionsThe lateral thoracic flap combined with the local flap to repair the chest wall soft tissue defect after tumor surgery is a strategic decision for surgical treatment, which is beneficial to the sequential surgical treatment of tumor patients.

Can surgeons rely on growth-related changes to achieve lip height and width symmetry in unilateral complete cleft lip repair?

Surgeons face difficulties achieving simultaneous lip height and width symmetry while repairing unilateral complete cleft lip, so one is often sacrificed at the expense of the other. The aim of this study was to evaluate the effect of growth on lip height and width symmetry, to guide the surgeon to the best decision. The study patients (N = 105) were divided into two groups based on the treatment method: 42 were treated with the modified rotational advancement technique (MRA group) and 63 with the Millard rotation-advancement technique (RA group). Furthermore, based on lip height and width symmetry at 6 months postoperative, the patients were divided into three groups: 38 with symmetrical lip height and width (SL), 41 with horizontal lip width more symmetrical than lip height (RAW), and 26 with vertical lip height more symmetrical than lip width (RAH). Measurements were taken preoperatively (T0), 6 months (T1) and 5 years (T2) postoperatively. The MRA group had significantly more symmetrical lip height than the RA group at T1 (P = 0.003) and T2 (P = 0.002); however no statistically significant difference in lip width symmetry was observed between the two groups. In relation to the effects of growth, only lip width symmetry in the RAH group improved significantly between T1 and T2 (P = 0.023). In conclusion the improvement in lip width symmetry following 5 years of postoperative growth did not achieve the same symmetry as when lip width symmetry was achieved intraoperatively. Thus, the MRA technique could be used to obtain intraoperative symmetry of lip height and width.

Rotation Advancement Distraction Osteogenesis Technique is Attributed to Unilateral Lambdoid Synostosis and is Used to Correct Posterior Plagiocephaly.

Unilateral lambdoid synostosis is the rarest form of craniosynostosis. Surgical correction is technically challenging from a morphological standpoint and is used to decompress intracranial pressure. Herein, the authors present a "rotational advancement bone flap" technique for the repair of posterior plagiocephaly. A bicoronal skin incision was performed, to expose the occipital region. The rotational advancement bone flap was designed to hinge off the nonsynostotic side, and it was set up to include an occipital protrusion on the normal side. On the premature side, an advancement bone flap was set up to include the flattened and deformed occipital bone. A titanium cranial distractor, which was attached between the bone flap and the anterior bone. An absorbable plate, which would later become a hinge due to the movement of the bone flap, was attached to the area for reinforcement. The authors technique was able to decompress intracranial pressure with satisfactory esthetic outcomes.

V-Y Rotation Advancement Flap for Sacral Sore: Experiences at Rajshahi

Grade III and Grade IV sacral pressure sores are required surgical closure. The gluteal fascio-cutaneous rotation advancement flap with V-Y closure was performed in our hospital on 50 cases of sacral sore from 2017 to 2019. The largest defects closed with a unilateral flap were up to 14 cm, and a bilateral flap needed to close 15-22 cm in diameter. In 1.5 to 24 months of follow-up time, none of the patients developed wound dehiscence or flap necrosis requiring repeated surgery. The V-Y rotation advancement flap technique is simple, can be performed quickly, has minimal associated morbidity, and has a good outcome. Furthermore, we can use the same flap design in recurrent cases.
 TAJ 2022; 35: No-1: 33-38

Comparative study of complete unilateral cleft lip repair by Millard’s rotation advancement procedure and triangular flap repair of Tennison

This study was done to evaluate and compare the surgical outcomes of primary repair of Complete Unilateral Cleft lip by Millard’s rotation advancement technique and Randall-Tennison’s Triangular flap technique in terms of Quantitative and qualitative assessments like cupid bow pouting, vermilion symmetry, nasal floor alar base symmetry and scar appearance was analysed by 5 different Plastic surgeons. 40 patients of complete Unilateral Cleft Lip operated using either Millard’s technique or Randall-Tennison’s Triangular flap technique (20 each) in the Department of Burns, Plastic and Reconstructive Surgery, SCB Medical College and Hospital, Cuttack for 2 years. They were compared with 20 normal patients (control). Overall mean age was 5.07 ± 1.41 months and 1st birth order comprised of 45.0%. Family history was found among 6.7% cases. 78.3% patients were in age group 3 – 6 month, 21.7% in 6 -12 months age group. Postoperatively there was significant difference in total nasal width between Tennison and control , Millard and Tennison but insignificant between Millard and Control.There was no statistical difference between Modified Millard’s rotation advancement technique and Randall-Tennison’s Triangular flap technique for the primary repair of the unilateral cleft lip under the hands of a qualified and skilled Plastic Surgeon.

Lip symmetry following rotation advancement cleft lip repair in 5-year-old children treated by Ralph Millard and Ron Pigott

ObjectiveTo compare the symmetry of the lip following Rotation-Advancement cleft lip repair by Millard and Pigott and to investigate the effect on the symmetry of cleft side and gender by using different surgical protocols. Symmetry following cleft surgery was compared to that of non-cleft children. DesignRetrospective study of photographs of children aged 5 years. SettingThree decades of post-operative photographs of children treated by Millard and Pigott. PatientsEighty-nine children treated by Millard, 87 by Pigott and 91 non-cleft children. InterventionsPhotographs were assessed using the Symnose Computer program, a rapid semi-objective quantitative assessment of lip symmetry. Main Outcome Measure(s)Asymmetry score for each surgeon, and non-cleft children. ResultsThere was no significant difference in the median lip % mismatch score of Millard, 36.65% and Pigott, 38.52%. Right-sided clefts showed better symmetry than left-sided clefts for Millard (p<.001). This was reversed for Pigott (P=.0121). There was a difference (P<.001) between the symmetry of the two cleft cohorts and the non-cleft children (asymmetry 19.9%), and between Millard's outcomes following different lip surgical protocols (P < .0001), but no difference between Pigott's outcomes using different palate surgical protocols (P = 0.59). ConclusionsCleft lip repair by Millard and Pigott resulted in similar lip asymmetry (37% and 39% symmetry mismatch, respectively). Lip surgical protocol and cleft side may affect lip asymmetry. Palate surgery did not affect lip asymmetry. Following cleft surgery, children were more asymmetric than non-cleft children.

Near Total/Total Lower Lip Reconstruction—Chin Rotation Advancement Flap

Summary: Total lower lip reconstruction is a challenging reconstruction procedure. Its main role is to restore lip function, maintain the proper relationship between the upper and lower lips and optimize cosmesis. Various techniques ranging from local flaps to free tissue transfer have been developed. For patients who are not candidates for microsurgical techniques or for those who do not want complex procedures, the local flap technique is a good solution. Most of the reported techniques, based on cheek advancement and nasolabial flaps, lead to scars located in the midface and therefore to unaesthetic results. We hereby present a novel technique for total lower lip reconstruction using a rotation advancement flap based on the excess tissue of the lower face. To our knowledge, this method has not been described previously in the literature.

Comparison of Outcomes of Millard's Rotational Advancement Flap and Fisher's Techniques for Surgical Correction of UCLD

Objective: The objective of our study is to compare the surgical outcomes of two surgical techniques namely Fisher’s technique and Millard’s Rotational Advancement Flap, particularly in terms of white roll symmetry, lip length, lip height, scar quality, notching, cupids bow and alar base symmetry. Study design: Prospective Randomized Clinical Trial study. Place and duration of study: Department of Pediatric surgery, Sheikh Zayed Hospital, Rahim Yar Khan for a period of six months from 1st March 2021 to 31st August 2021. Patients and method: A total of 56 patients were enrolled in the study, equally divided into two groups. Group 1 will include patients undergoing treatment via Millard's Rotational Advancement Flap technique, while group 2 will include those receiving Fisher's procedure. A single consultant performed the procedure. Variables like lip length, Alar base symmetry, scar quality, cupids bow symmetry, and notching were accessed postoperative via the Steffensen grading method, and Vernier caliper was used for anthropometric measurements. The SPSS v 23 was used to evaluate the data. All numerical data were provided in mean and standard deviation (SD) formats. Frequencies were computed for qualitative data. Nonparametric tests (paired and unpaired t-tests) and parametric tests (Fisher's exact test) were utilized to compare the variables. P-value of &lt; 0.05 was considered statistical significant. Results: Both groups had identical outcomes in terms of lip length, nasal symmetry, and alar dome. On the other hand, Fisher's approach was superior in terms of vermilion roll symmetry, white roll symmetry, scar appearance, and Cupid Bow. Anthropometric measures, such as lip height and breadth, were taken; however, the results were statistically insignificant. There was no discernible difference between the outcomes of complete and incomplete cleft lip. Conclusion: We propose using the Fisher's surgical method in unilateral cleft lip repair since it produces better outcomes than the Millard's procedure. Keywords: Anthropometric measurement; Fisher; Lip Notching; Millard; Scar; Unilateral cleft lip.

Burow’s Triangle Rotational Advancement Flap with Accelerated Partial Breast Irradiation for Upper Inner Quadrant Early Breast Cancer

Burow’s Triangle Rotational Advancement Flap with Accelerated Partial Breast Irradiation for Upper Inner Quadrant Early Breast Cancer

Rotation Advancement Keystone Flap for Closure of Large Myelomeningocele Defects.

Myelomeningocele is the most common form of neural tube anomalies. Early reliable skin coverage should be achieved to reduce central nervous system infections. The keystone flaps are gaining popularity for myelomeningocele defect reconstruction. However, the use of a traditional keystone flap is limited in very wide or transversely oriented myleomeningocele defects with inadequate lateral tissue laxity. In this study, we present our successful experience using modified rotation advancement keystone flaps for closure of the transversely oriented myelomeningocele defects. Between April 2019 and April 2020, the modified rotation advancement keystone flap was used for reconstruction of transversely oriented myelomeningocele defect in 7 patients (5 males and 2 females) with average age of 14 days. The localization of the lesions was lumbosacral in 5 patients and thoracolumbar in 2 patient. The average myelomeningocele defect width was 6.4 cm, whereas the average defect length was 5.7 cm. The following information was evaluated: the flap dimensions, operative time, and postoperative complications. All patients had uneventful operations, except for 1 case of superficial epidermolysis over flap tip, which settled with conservative wound management. Immediate venous congestion was detected in 2 patients that completely resolved. Otherwise, all wounds healed without any evidence of complications. The mean follow-up was 4 months. Although the conventional keystone flap seems to have geometric constraints to close a transversally oriented myelomeningocele defect, the modified rotation advancement keystone flap serves as a superior alternative and effective option for closure transversally oriented defect.

The Use of a Hemi Glabellar Flap for Reconstruction of Medial Canthus Defects.

Background: Medial canthal reconstruction is a challenging task due to its complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum horizontal scarring, which is aesthetically displeasing, and possible injury of the supratrochlear artery. Multiple variations have been proposed in the literature, which is often complex. In this paper, the senior author (AK) has developed an intuitive, simple technique by utilising half of the glabellar skin in 12 patients with good clinical outcomes.Materials and methods: A rotational advancement flap involving the upper lateral nasal wall with the hemi glabellar was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients.Results: Reconstruction using the hemi glabellar technique was performed on 12 patients following resection of basal cell carcinoma (BCC) in or near the medial canthus area. Superficial cellulitis was noted in two patients; they were managed on oral antibiotics. Bruising was reported in seven patients which resolved spontaneously in 4-7 days. All patients had a good outcome at two months and six months follow up; there was no flap loss, and all patients were satisfied with the aesthetic outcome.Conclusion: The technique highlighted in this article can be performed quickly and applies to the reconstruction of medial canthus defects with excellent aesthetic outcomes, an inconspicuous scar and supple skin with matching colour.

Management of basal cell carcinoma with excision followed by rotation advancement flap

Background: Basal cell carcinoma (BCC) is the most common malignant skin tumor and is derived from pluripotent cells in the basal layer of the epidermis. One of the BCC management options is surgery followed by a skin flap to close the wound defect. Case Illustration : We present a 43-year-old woman with a major complaint of non-healing sores on the left zygomatic region, close to the medial canthus, with frequent episodes of bleeding and itching since one year before admission. The lesion was excised and followed by histopathological examination, which revealed the BCC diagnosis with tumor-free edges. Closure of the defect with a rotation advancement flap was performed with good results. Discussion : The diagnosis of BCC in this patient was based on history taking, dermatological and histopathological examination. According to the dermatological examination, the patient presented with superficial ulcers with hyperpigmented bases, irregular margins and raised edges, partly covered by crust in the left zygomatic region, consistent with typical clinical manifestation of BCC. Histopathological findings of BCC may vary according to the subtype. However, most cases of BCCs usually have similar histological characteristics. Conclusion : The functional and cosmetic result of BCC following excision and defect closure with rotation advancement flap yielded good results with a shorter healing time. &nbsp; Keywords : basal cell carcinoma, excision, management, rotation advancement flap

Segmental Maxillomandibular Rotational Advancement (SMMRA) in the Treatment of Adult Patients with Severe Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) occurs as an increased collapsibility of the upper airway during sleep, which threatens health and quality of life. Asian men with greater severity of OSA presents less obese and are connected with craniofacial abnormalities. Although the traditional maxillomandibular advancement (MMA) had the comparable effectiveness to the continuous positive airway pressure therapy, the midfacial esthetics might be compromised in Asian individuals. The modified MMA procedure was proposed to balance the esthetic demands and improvement of OSA symptoms. The case report showed a 25-year-old man presented with a diagnosis of severe OSA. The pretreatment Apnea Hypopnea Index (AHI) score was 100 events/h. He exhibited skeletal Class II hyperdivergent facial pattern with mandibular retrognathism. To correct dentofacial deformities and improve sleep function, the modified surgical-orthodontic procedure was undertaken. The surgery-first approach was adopted for early improvement of OSA. The surgical procedures of SMMRA comprise the maxillary LeFort I segmental osteotomy, bilateral sagittal split osteotomy and genioglossus-genioplasty osteotomy. The counterclockwise rotation of maxillomandibular complex was further done to maximize mandibular advancement. The total treatment duration was 13 months. The well-aligned dentitions and solid dental occlusion were achieved. The subjective perception of sleep quality was improved. The patient was satisfied with the post-treatment facial appearance. Following the skeletal movement, the dimension of pharyngeal airway space was increased. The post-treatment AHI score was reduced to 12.1 events/h; the nadir oxygen saturation increased from 74% to 86%. The case report demonstrated the SMMRA procedure effectively improved adult Asian patients with severe OSA without deterioration of facial attractiveness and dental occlusion.

Modified Rotational Advancement Technique for Primary Unilateral Complete Cleft Lip Repair.

Importance: Leveling Cupid's bow while maintaining lip height and width in unilateral complete cleft lip patients with improved nose outcomes is a significant challenge for surgeons. Objective: This study aimed to measure the symmetry of the nasal and labial anthropometric points after using this modified cleft lip repair technique. Design, Setting, and Participants: In this retrospective study, 72 consecutive nonsyndromic unilateral complete cleft lip patients underwent a modified rotational advancement technique. Photos of at least 1 year follow-up period were collected. Main Outcomes and Measures: The nose measurements included columella length, nostril height and width, ala width, nostril inclination, columella angle, and ala bases angle. The lip measurements included lip height and width, vermillion height; midline-philtrum angle, and angles of Cupid's bow peaks. Descriptive quantitative analysis of the lip and nose measurements, intraclass correlation coefficient, and ANOVA tests were conducted. Results: Well-aligned Cupid's bows with symmetrical lip height and width were obtained with satisfactory aesthetic nasal outcomes. Conclusions: The present technique had leveled the Cupid's bow while preserving the lip height and width, with resultant satisfactory nasal outcomes.

A Normative Observational Study of the Relationship of the Philtral Ridges to the Columellar Base in South-Indian Population and its Significance on Cleft Lip Repair.

Introduction The philtral ridges form a prominent visual landmark in the upper lip. An aesthetically pleasing cleft lip repair should restore this preferably without any scars cutting across it. Although there are several scientific publications on morphology of this structure and its variations, very few studies on the Indian population have been published. Aim To study the morphology of the philtral ridges and their relationship to the columellar base in normal Indian children and its significance in cleft lip repair. Methods 115 normal healthy children from southern India aged between one and 12 years were studied based on direct observation of the relationship of the superior end of the philtral ridge to the columellar base and nasal sill. In type A, the philtral ridge terminates at the nasal sill just lateral to the columellar base, and in type B, it either reaches or fades before reaching the columellar base. All observations were performed by the first author by examining standardized two-dimensional (2D) photographs of the upper lip-nose complex. Results In this study, 74% of the subjects had the philtral column extending lateral to the columellar base. Conclusion These finding assume a significance since, in a substantial proportion of the studied population, techniques of cleft lip repair such as the rotation advancement method, place a scar that crosses the upper third of the philtral ridge which may be undesirable.

Principalization of the Anatomical Subunit Approximation Technique of Unilateral Cleft Lip Repair

Background: The Anatomical Subunit Approximation cleft lip repair advantageously achieves a balanced lip contour with the line of repair placed along seams of aesthetic subunits. Since Fisher’s original description, it has been adopted widely and adapted, but some surgeons find the transition away from a cut-as-you-go approach challenging. Methods: We present an adapted Anatomic Subunit Approximation technique based on essential components of Fisher’s repair. The order of surgical execution is emphasized. Paradigm shifts are presented to help the surgeon used to more traditional rotation advancement techniques understand the Subunit philosophy. Minor adaptations such as surgically releasing lateral lip elements prior to marking are discussed. Results: A total of 53 eligible patients were treated with unilateral cleft lip repair by the senior author (D.C.) between February 2008 and April 2012 at Royal Children’s Hospital in Melbourne, Australia. Representative cases were chosen to demonstrate achievable results with the described technique. Conclusion: The proposed technique employs essential skin markings to achieve an anatomic subunit approximation lip repair, and appears to facilitate surgical outcomes with a high degree of symmetry. Core principles of repair include precise anatomical planning, tissue component separation, and muscle-driven advancement.

Millard's rotation advancement technique for unilateral cleft lip repair

The unilateral cleft lip deformity includes defects of the lip and also the associated deformities in the nose. The Millard's rotation advancement technique is a versatile one for the repair of these deformities. The principle of the technique is that the raised Cupid's bow point medial to the cleft is brought down level with its noncleft side counterpart by a rotation incision, which extends to the base of the columella and ends with a back cut. The resulting defect beneath the base of the columella is filled with an advancement flap from the cleft side. The advantages of the techniques are many. The most significant one is that it adheres to the basic principles of esthetic surgery, with the main scars being along the relaxed skin tension lines. It is a versatile technique producing optimal results in all types in unilateral cleft lip patients ranging from the microform to the widest of complete clefts. The incision in this technique is so placed that there is easy access to address the associated defects of the nose. Technical refinements have been added to the classical description of the procedure to address the deficiencies in the repair. We describe important refinements introduced at our center by Dr. H. S. Adenwalla. Universally, this technique is still the most popular.

57 The Use of a Hemi Glabella Flap for Reconstruction of Medial Canthus Defects

Abstract Background Medial canthal reconstruction is a challenging task due to the complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum and horizontal scarring which is aesthetically displeasing. The senior author in this paper has developed an intuitive modification to the technique. Method A rotational advancement flap involving the upper lateral nasal wall with the hemi glabella was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients. Results Reconstruction using the Hemi-Glabellar technique was performed on 12 patients following resection of BCC in or near the medial canthus area. Superficial cellulitis was noted in 2 patients, they were managed oral antibiotics. There was bruising in 7 patient which resolve spontaneously in 4-7 days. All patients had a good outcome at 2 months and 6 months follow up. There was no flap loss and all patients were satisfied with the aesthetic outcome. Conclusions The technique highlighted can be performed easily and is applicable to reconstruction to defects of the medial canthus with excellent aesthetic outcomes with an inconspicuous scar and supple skin with matching colour

FISH Mastectomy Incision: an Innovative AIIMS Technique

In obese patients following standard mastectomy for breast cancer, redundant skin persists at the lateral end of the mastectomy scar. It can be uncomfortable and unsightly. Moreover, uneven surface of skin fold especially in axilla increases the risk of radiation reaction. The standard transverse elliptical incision at the lateral end of mastectomy incision can be modified as a fish tail to avoid dog-ear deformity of the wound. This design of the incision enables the surgeon to mobilise the redundant skin employing the principle of ‘rotation advancement’ and close even large skin defects.

Reconstruction of Congenital Alar Rim Defects (Tessier Number 1 Cleft) Using Laterally Based Alar Subunit Rotation Advancement Flap.

Alar rim defects develop in most cases as a result of burns, trauma, or tumor excision. Congenital alar rim defects are rare, with an incidence of 1 in 20,000 to 40,000 live births. Tessier classification is the most commonly used classification system for craniofacial defects. Facial clefts involving the nose are categorized as types 0, 1, 2, and 3, whereas cranial clefts with nose lesions are categorized as types 11, 12, 13, and 14. The patterns of nasal clefts are extremely variable, ranging from a simple notch of alar margin to complex craniofacial cleft involving the lip, nose, eyelid, brow, forehead, and underlying bone. This study was conducted at Fayoum University Hospital on 8 male patients who present with congenital alar rim defects (Tessier number 1 cleft). Surgeries were performed under general anesthesia with orotracheal intubation. A full-thickness incision was created along the whole alar subunit, keeping the ala attached only laterally (laterally based alar full-thickness flap). The alar flap was advanced and rotated medially and inferiorly and sutured to the anatomical place in 2 layers, skin and mucosa. Follow-up was done at least 1.5 years postoperatively. The study was conducted on 8 male patients presenting with congenital alar rim defects (Tessier number 1 cleft). The mean age of patients was 14.2 years, and the cleft was unilateral in 4 patients (50%) and bilateral in 4 patients (50%). The patients were assessed both aesthetically and functionally and followed at 1.5 years postoperatively. The aesthetic outcome was assessed according to both patients' and author's evaluations of the scar appearance, alar symmetry, nostril symmetry, and general satisfaction. Laterally based alar subunit rotation advancement flap is a reliable option for reconstruction of congenital alar rim defects (Tessier number 1 cleft) with the advantages of being an easy single-stage procedure with good tissue matching and nostril symmetry and only limitation of extremely wide defects with deficient tissues between the ala and tip.