Single Flap Research Articles

Challenges in multi-unit reconstruction: a framework perspective

Locally advanced or recurrent head and neck cancer can present both oncologic and reconstructive challenges. There are no current guidelines for reconstruction of multi-unit defects, yet reconstructive goals should serve the purpose of providing a safe healing environment for both adjuvant therapy and functional rehabilitation. In light of a younger head and neck cancer population, reconstructive methods aimed at preserving form and function over a long survivorship period are optimal. The review of the literature regarding use of single or double free flaps, with or without locoregional reconstructive options, and new techniques for multi-unit defects is described. Managing complex defects with multiple units involves determining a framework of critical, optimal, and optional elements for each reconstruction with consideration of the medical tolerance of the patient and long-term functional rehabilitation. Multi-unit reconstruction should involve distinction of critical, optimal, and optional aspects to provide a safe healing environment for both adjuvant therapy and functional rehabilitation fit for long-term survivorship.

Results of Single and Double Flap Anastomosis in External Dacryocystorhinostomy Surgery

Background: Dacryocystorhinostomy (DCR) is one of the most common oculoplastic surgeries. In this study, we aimed to compare single and double flap anastomosis results in external dacryocystorhinostomy surgery. Materials and Methods: Between January 2016 and November 2017, 156 patients who underwent external DCR were evaluated retrospectively. All cases were performed under general anesthesia. In the first group, 86 patients (52 female, 34 male) had a double flap external DCR. In the second group, 70 patients (40 female, 30 male) had a single flap external DCR. Results: The mean follow-up period was 18.2±8.6 months in the double flap group and 16.4±5.4 months in the single flap group. The mean age was 48.2±16 in the double flap group and 46.3±17 in the single flap group. The success rate was 96.6% in the double flap group and 95.8% in the single flap group. Conclusion: In our study, there was no difference in surgical success in patients undergoing single and double flap external DCR surgery.

Simultaneous Bilateral Microtia Reconstruction Using Single-Expanded Postauricular Flap Without Skin Grafting.

Auricular reconstruction in patients with congenital microtia permits craniofacial balance and harmony, especially in patients with bilateral microtia. However, published techniques usually require skin grafting, which can lead to color mismatch and visible scarring. Some surgeons prefer to reconstruct the auricle of each side separately, which prolongs the complete cycle of surgery and increases suffering of the patient. In this study, we introduce a modified technique using single expanded flaps without skin grafting to achieve simultaneous bilateral auricular reconstruction. Between January 2012 and January 2017, a total of 54 patients with bilateral microtia underwent auricular reconstruction with expanded single flaps. Simultaneous bilateral auricular reconstruction was accomplished through 3 surgical stages. In the first stage, bilateral postauricular skin was expanded using 2 kidney-shaped tissue expanders. In the second stage, bilateral rib cartilage was harvested using minimal incisions, allowing 2 modified 3-layer frameworks to be fabricated. Each framework was then inserted into the pocket through the same incision with subsequent closure using 2-layer suture. In the third stage, the reconstructed ears were further trimmed, if necessary, and the lobules and tragus reconstructed. All the patients were followed up for 6 to 24 months. During follow-up, patients were satisfied with surgical outcome in terms of size, shape, location, detailing, and symmetry of the bilateral ears in more than 50 cases. Only 4 demonstrated postoperative complications. No skin necrosis, exposure of cartilage, or infection was observed or postoperative chest deformities. Simultaneous bilateral auricular reconstruction using single expanded flaps combined with a modified 3-layer cartilage framework is an effective technique for patients with bilateral microtia.

Wake effect assessment of a flap type wave energy converter farm under realistic environmental conditions by using a numerical coupling methodology

Ocean Energy Europe has estimated that 100 GW of ocean energy capacity (wave and tidal) could be deployed in Europe by 2050. Along with the European targets it is expected that large farms of Wave Energy Converters (WECs) will be installed in the sea and, as part of the consenting process for their installation, it will be necessary to quantify their impact on the local environment. The objective of this study is to improve the assessment of WEC farms impact on the surrounding wave field (wake effect) through the use of a numerical coupling methodology. The methodology consists of a Boundary Element Method (BEM) solver to obtain the wave perturbation generated by the WEC farm for the near-field accounting for the wave-body interactions within the farm whilst a Wave Propagation Model (WPM) based on the mild-slope equations determines the wave transformation in the far-field. The near-field solution obtained from the BEM solver is described as an internal boundary condition in the WPM and then it is propagated throughout the WPM numerical domain. The internal boundary is described by imposing the solution of the surface elevation and velocity potential at the free-surface at each instant of time along a line surrounding the WEC farm.As a case study the methodology was applied to flap type WECs that are deployed in shallow water conditions. The validation of the technique was done first for a single flap and then for a farm of 5 flaps. Once validated, a realistic scenario was assessed by quantifying the impact of irregular sea states composed of long crested waves on a large WEC farm composed of 18 flaps and located on a real bathymetry. The irregular waves were obtained by superposing the regular wave field solutions for all wave frequencies represented in the considered sea state based on the linear water wave theory. Within the limits of this theory these simulations demonstrate the versatility of the methodology to accurately represent the impact of a WEC farm on the surrounding wave climate. The influence of the peak period and the spacing between flaps on the WEC farm wake effect was assessed as well.

Regenerative Periodontal Treatment with the Single Flap Approach in Smokers and Nonsmokers.

The present study was performed to evaluate the impact of smoking status on 6-month clinical outcomes of a regenerative procedure based on enamel matrix derivative and deproteinized bovine bone mineral in the treatment of intraosseous defects accessed with buccal single flap approach. A total of 22 defects were selected in smoking (n = 11) and nonsmoking (n = 11) patients. Regenerative treatment resulted in similar clinical attachment level (CAL) gain in both smokers and nonsmokers. A trend toward lower 6-month CAL gain and probing depth reduction was observed in patients smoking 11 to 20 cigarettes per day compared to those smoking 1 to 10 cigarettes per day.

PC087: Effects of single flap corticotomy‐assisted orthodontic treatment on thin type periodontium. A case series

PC087: Effects of single flap corticotomy‐assisted orthodontic treatment on thin type periodontium. A case series

O062: Regenerative periodontal treatment with the Single Flap Approach in smokers and non‐smokers

O062: Regenerative periodontal treatment with the Single Flap Approach in smokers and non‐smokers

Abstract 143: Comparative Analysis of Single versus Stacked Free Flap Breast Reconstruction: A Single Center Experience

BACKGROUND: As breast reconstructive microsurgeons increase their armamentarium of flaps with experience, need for stacked and multiple flaps may generate an improved aesthetic outcome. We present our institutional experience of using single vs. multiple free flap breast reconstruction. METHODS: 769 flaps were performed on 427 patients from 2010–2016 by two senior surgeons at a university hospital. 197 of those flaps were either: Stacked PAP flaps, 4-flap (Bilateral PAP+Bilateral DIEP flap), or Double-pedicle DIEP/SIEA flaps. 595 flaps were either: unilateral or bilateral DIEP or PAP flap. Demographic, patient co-morbidities, and flap complications were compared between the 2 groups. RESULTS: Out of 427 patients, 322 patients (595 breast reconstructions) underwent single DIEP or PAP flap while 105 patients (197 flaps in 113 breasts) underwent multiple free flaps. The multiple flap patient group had statistically lower BMI, longer procedure time, had smaller flaps, and higher DVT compared to single flap group. There were no statistical differences in the rates of flap loss (1.3% in multiple flaps versus 1.7% in single flap), wound complication, hematoma, and PE. CONCLUSION: Based on our large experience, stacked/multiple flaps are safe and preferred in properly selected patients with low volume from a unilateral donor site, exhibiting similar complications and success rates compared to single-flap patients. The ability to use multiple donor sites may represent a unique phase of innovation in breast microvascular surgery, with high patient tolerance and aesthetically pleasing results geared towards reconstructing breasts in all subunits. We present our indications and approach for successful multiple flap reconstruction. M. Cho: None. A. Hembd: None. C. Venutolo: None. S.S. Teotia: None. N.T. Haddock: None.

Simplified procedures to treat periodontal intraosseous defects in esthetic areas.

Successful treatment of deep intraosseous defects in esthetic areas implies clinical improvement of the lesion consistent with long-term tooth survival as well as the preservation (or improvement) of esthetics. It is hoped that such treatment end points may be reached through procedures (which we have termed as 'simplified') that, on the one hand can be easily and successfully applied by the majority of clinicians, and, on the other hand, are well tolerated by patients in terms of postsurgical pain and discomfort, adverse events and cost. In this review, we describe the technical aspects of the simplified procedures currently available (i.e. nonsurgical therapy and the single flap approach and its variants). Also, we analyze the effect of such procedures on clinical parameters and patient-centered outcomes. While nonsurgical therapy seems to be appropriate per se in lesions with a probing depth of < 7 mm and a limited intraosseous component, severe intraosseous defects can be successfully treated using simplified surgical procedures. Overall, data support the effectiveness of simplified surgical procedures and indicate that they result in minimal esthetic impairment (i.e. post-treatment recession) and a more tolerable postoperative course when compared with conventional surgical (double flap) approaches. In particular, the single flap approach was shown to be at least as effective as traditional papilla-preservation techniques when evaluated either as a stand-alone protocol or in combination with regenerative devices. Bioactive agents have shown the most appropriate regenerative technology when used in association with simplified surgical procedures.

Outcomes after free tissue transfer for composite oral cavity resections involving skin.

Resections involving oral cavity mucosa, bone, and skin present a unique challenge. Optimizing outcomes often requires technically demanding reconstruction. The purpose of this study is to evaluate outcomes of several reconstructive approaches for patients with composite through-and-through defects, with a focus on the osteocutaneous radial forearm free flap (RFFF). We conducted a retrospective evaluation of the cohort of patients treated for composite through-and-through defects with cutaneous involvement who underwent free flap reconstruction from August 2012 through October 2015. Seventeen patients received a single flap (12 cases of osteocutaneous RFFF), whereas 10 patients underwent a combination of flaps. Complication rates and functional outcomes were favorable in patients who underwent osteocutaneous RFFFs. The supraclavicular artery island flap (SCAIF) was used as a second flap in 3 cases. The osteocutaneous RFFF provides a valuable reconstructive option for complex composite resection defects involving skin. When 2 flaps are required, the SCAIF is a viable alternative to a second free flap or pectoralis flap.

Simultaneous treatment of sacral and ischial pressure ulcers with a single flap: case presentation

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

Mathematical model of snake-type multi-directional wave generation

Research on extreme wave generation is one intensive research on water wave study because the fact that the occurrence of this wave in the ocean can cause serious damage to the ships and offshore structures. One method to be used to generate the wave is self-correcting. This method controls the signal on the wavemakers in a wave tank. Some studies also consider the nonlinear wave generation in a wave tank by using numerical approach. Study on wave generation is essential in the effectiveness and efficiency of offshore structure model testing before it can be operated in the ocean. Generally, there are two types of wavemakers implemented in the hydrodynamic laboratory, piston-type and flap-type. The flap-type is preferred to conduct a testing to a ship in deep water. Single flap wavemaker has been explained in many studies yet snake-type wavemaker (has more than one flap) is still a case needed to be examined. Hence, the formulation in controlling the wavemaker need to be precisely analyzed such that the given input can generate the desired wave in the space-limited wave tank. By applying the same analogy and methodhology as the previous study, this article represents multi-directional wave generation by implementing snake-type wavemakers.

Quoi de neuf en dermatologie instrumentale ?

This "What's new in instrumental dermatology" dedicated skin surgeryis based upon a 2015-2017 literature analysis. The excision of skin cancers is an important part of surgical dermatology. Will artificial intelligence and new drug be able to face the increasing need for therapy? Wrong-site surgery is due to multiple factors. Photographs of biopsy site and short time between biopsy and surgery decrease postponement of surgery and wrong-site surgery. Noninvasive imaging technologies are improving and help to delineate skin tumors and increase the probability of complete tumor removal. They are beginning to be an essential tool for skin surgery. The 2005 recommendations for the management of melanoma stages I to III have been updated in 2016. The Slow-Mohs technique is the better way to treat dermatofibrosarcoma protuberans whose sub-clinical invasion is often asymmetric and unpredictable. Wide local excision for the treatment of severe hidradenitis suppurativa improves the quality of life and decreases recurrence rate. Cutaneous surgery is considered as safe procedures with a low risk of complications. Postoperative bleedings are the most frequent. Anti-thrombotics enhance the risk, but must not be stopped or bridged, except the novel oral anticoagulants which can be interrupted 24h before surgery and started again a few hours after. The risk of surgical site infections is low in dermatologic surgery. Most recommended measures to prevent them have been extrapolated from other types of surgery and the level of evidence is low. The reconstruction of skin defect must be adapted on size and location. A birhombic transposition flap is reliable in case of a defect too large to be repaired by a single flap. Full-thickness skin graft is a safe option to repair defect on the external ear.

The superiorly based bilobed flap for nasal reconstruction

The laterally based bilobed flap is commonly used for the reconstruction of small- to medium-sized defects of the distal portion of the nose; However, when this flap is used to repair defects that are larger, more cephalic, or more lateral on the nose, there is a risk for lower nasal distortion. Reorienting the base superiorly preserves the advantages of the traditional design while minimizing this risk. To demonstrate the design, execution, and efficacy of the superiorly based bilobed flap. A retrospective review examined all superiorly based bilobed flaps performed by 1 surgeon (J.C.) in 2000-2016 after tumor extirpation by Mohs micrographic surgery at a single institution. A total of 41 surgical defects were closed with 40 flaps between June 2000 and August 2016 (1patient had 2 defects closed with a single flap). Of the tumors, 55% were located on the nasal dorsum, and the median of the longest postoperative tumor axis was 1.4cm. Follow-up was available for 40 flaps, and no infections, hematomas, or episodes of full-thickness necrosis were observed. Data were collected retrospectively from a single institution without a standardized assessment tool for aesthetic outcomes. The superiorly based bilobed flap is useful for nasal reconstruction.

Medial canthal reconstruction with multiple local flaps

BackgroundIt is often difficult to reconstruct comparatively large defects in the medial canthal region. The authors have performed reconstruction with multiple local flaps in 4 medial canthal defects after resection of malignant skin tumors. MethodThe defects exceeded the medial canthal region, extending to the upper eyelid and the lower eyelid. The medial canthal defect was covered by transposition of a glabellar flap, the upper eyelid defect was covered by an upper eyelid myocutaneous advancement flap, and the lower eyelid defect was covered by a cheek rotation flap. Then the donor site of the glabellar flap was covered by a Rintala flap. ResultsThere was no recurrence in any of the cases, and good results were obtained. One case showed mild linear contracture, but the patient did not want corrective surgery. ConclusionThis method is somewhat complicated compared to reconstruction with a single flap, but it is a combination of standard local flaps and is a simple reconstructive procedure. By adding additional resection, the suture line is consistent with the border of the facial unit, so postoperative scarring is inconspicuous. This technique is aesthetically useful because of the continuity of colour and texture resulting from the use of adjacent flaps.

Do rhomboid flaps provide more elongation than Z-plasty flaps? An experimental study

Background and aim: A Z-plasty flap is one of the most widely used geometric relaxation methods to release contracture bands. A rhomboid flap is a lesser used geometric relaxation method than a Z-plasty flap. This study aimed to determine the length and rate of elongation provided by rhomboid and Z-plasty flaps.Methods: Bilateral contracture bands were created in the inguinal skins of rats. A rhomboid flap was planned for the right side of the inguinal region, and a single Z-plasty flap was planned for the left side. The length and rate of elongation provided by the two flaps were calculated after completing the procedures and were compared using Student’s t-test.Results: Experimental contracture bands disappeared in both the inguinal regions after creating rhomboid and Z-plasty flaps. The mean postoperative elongation of the contracture band was 1.4 ± 0.119 and 2.47 ± 0.281 cm using the rhomboid and Z-plasty flaps, respectively. The difference was statistically significant (p < .001).Conclusion: Z-plasty flaps provide more elongation than rhomboid flaps and also appear to be better options for releasing linear contracture bands. However, rhomboid flaps may be used as alternatives when Z-plasty flaps cannot be used and in regions such as the axilla, genital region, nipple-areola, where their distortion effects should be avoided.

Dorsal thumb rotated single pedical reverse island flap repaired thumb tip defect

Objective To evaluate the outcomes of thumb reconstruction with dorsal thumb rotated single pedicel reverse island flap. Methods 49 thumb-tip defects cases with dorsal thumb rotated single pedicel reverse island flap were analyzed retrospectively.37 dorsal thumb reverse island flap were performed, and 12 ulnar-dorsal reverse island flaps were performed. Results The operation time was 40-60 minutes.The mean time was 45 minutes.All 49 cases survived completely.The color of the flaps was purple, and blisters in the surface of the flaps after 1-2 days in 2 cases.After took out stitches partly, the blisters were dried and crusted, the color of the flaps with better blood circulation was normal.The follow-up period was 3-24 months, all thumbs had satisfactory appearances and functions.The two-point discrimination was 6-9mm in flaps inosculated with nerve, that was 8-10 mm in flaps inosculated without nerve.The color, texture and elasticity of flaps were excellent, and the donor sites had not been defected. Conclusion Dorsal thumb rotated single pedicel reverse island flap is a reliable option to restore function as well as appearance, long vascular pedicle with skin strap, wide rotation angle, high rate of survival.It avoided damages to the well-known arteries and nerves.It is a relatively facile procedure that can be applied toward resurfacing thumb tip defects. Key words: Hang injuries; Surgical; Microsurgery

BRANT (BREAST RECONSTRUCTION AND NODE TRANSPLANTATION) - A ONE-STAGE TRANSPLANTATION OF INGUINAL LYMPH NODES AND DELAYED BREAST RECONSTRUCTION. MODERN CONCEPT IN RECONSTRUCTIVE MICROSURGERY OF LYMPHATIC SYSTEM LESIONS

Secondary lymphedema is one of the common complications after complex treatment of breast cancer. One of the promising methods of treatment of lymphatic edema at the moment is microsurgical autotransplantation of inguinal lymph nodes. Only one method for treating lymphatic edema with a one-stage breast reconstruction was the concept of TBAR (Total Breast Anatomy Restoration), which implies the use of an inguinal lymphatic flap in the unfree variant - with the inclusion of its DIEP flap for delayed breast reconstruction. Cons - the concept is limited to using only the DIEP flap. A patient suffering from lymphatic edema and in need of breast reconstruction may not have enough tissue on the anterior abdominal wall. Therefore, our goal was to create an alternative concept, not tied to a single flap. BRANT (Breast Reconstruction And Node Transplantation) means microsurgical autotransplantation of the inguinal lymph flap into the axillary region and the use of any of the available flaps, to restore anatomical structures and to replenish the volume of the breast. The proposed method allows achieving the following results: for the minimal amount of surgical interventions an attractive type of breast is restored and good results are achieved in the treatment of lymphatic edema of the hand.

Weichgewebsaugmentation in der regenerativen Parodontalchirurgie

Trombelli L et al. Effect of a Connective Tissue Graft in Combination with Single Flap Approach in the Regenerative Treatment of Intraosseous Defects. J Periodontol 2017; DOI: 10.1902/jop.2016.160471

The power-capture of a nearshore, modular, flap-type wave energy converter in regular waves

Bottom-hinged, nearshore flap-type wave energy converters (WECs), have several advantages, such as high power conversion efficiency and survivability. They typically comprise a single flap spanning their full width. However, a potentially beneficial design change would be to split the flap into multiple modules, to make a ‘Modular Flap’. This could provide improvements, such as increased power-capture, reduced foundation loads and lower manufacturing and installation costs. Assessed in this work is the hydrodynamic power-capture of this device, based on physical modelling. Comparisons are made to an equivalent ‘Rigid Flap’. Tests are conducted in regular, head-on and off-angle waves. The simplest control strategy, of damping each module equally, is employed.The results show that, for head-on waves, the power increases towards the centre of the device, with the central modules generating 68% of the total power. Phase differences are also present. Consequently, the total power produced by the Modular Flap is, on average, 23% more smooth than that generated by the Rigid Flap.The Modular Flap has 3% and 1% lower average power-capture than the Rigid Flap in head-on and off-angle waves, respectively. The advantages of the modular concept may therefore be exploited without significantly compromising the power-capture of the flap-type WEC.