Single-stage Closure Research Articles

OEIS Syndrome: Omphalocele, Exstrophy of the Cloaca, Imperforate Anus, and Spinal Defects

OEIS Syndrome: Omphalocele, Exstrophy of the Cloaca, Imperforate Anus, and Spinal Defects

Evaluation of Bone Regeneration in Single Stage Closure of Cleft Alveolus with Gingivoperiosteoplasty

Background: Cleft alveolus closure is a challenge for cleft surgeon for many decades. Secondary alveolar bone grafting (SABG) is the preferred technique using autologous cancellous ileac crest bone as the donor graft. Many alternative methods were tried over the years with no any promising results. Gingivoperiosteoplasty (GPP) is a good alternative surgical technique for bone regeneration in cleft alveolus with proper case selection criteria. Aim: Aim of the study was to evaluate the bone regeneration following closure of cleft alveolus with gingivoperiosteoplasty. Method: This study was carried out in the department of Oral and Maxillofacial Surgery, Yenepoya Dental College, Deralakatte, Mangalore, Karnataka, India, from March 2018 to July 2019. In this study, we have performed gingivoperiosteoplasty with palatoplasty and evaluated the amount of bone formation in the cleft alveolus using a series of intra oral periapical radiographs. Five patients who required surgical repair of unilateral cleft palate and alveolus were selected for the study. Clinical and radiographical assessment was done post operatively, after three and six months respectively for anatomical function and bone formation. Results: After completion of clinical studies on patients, the statistical analysis of the data obtained. Radiographs were analyzed for grey scale density by means of adobe photo shop using the MATLAB process by histogram comparison in three months and six months, showing denser grey scale pattern, indicating the new bone formation in the cleft alveolus surgical site, in all the 5 surgical cases. Conclusion: Gingivoperiosteoplasty (GPP) is a good alternative procedure to secondary alveolar bone grafting (SABG), so donor site morbidity can be avoided with reduced time and cost for the surgery. But a larger sample size and longer follow-up are necessary to understand the better reliability of this surgical technique. Clinical Significance: Gingivoperiosteoplasty in cleft alveolus patients showed significant bone formation in 3 to 6 months postoperatively.

Single-Stage Closure of Congenital Sternal Cleft: Two Case Reports

Single-Stage Closure of Congenital Sternal Cleft: Two Case Reports

Incidental durotomy: intraoperative aid in ten steps

Management of the intradural structures safely, closure of the dura according to the tear, and minimizing the epidural dead space. Incidental durotomy (ID). None. 1.Bone removal until whole dural tear is visible (if necessary); 2.intradural inspection; 3.reposition the fibers; 4.perform an inside patch (if ID > 5 mm); 5.dural closure; 6.outside patch; 7.Valsalva maneuver; 8.epidural pedicled muscle flap; 9.multilayer wound closure; 10.lumbar drainage of cerebrospinal fluid (if necessary). Bed rest up to 48 h; analgesics. The intraspinal part of 4020 surgeries performed with the aid of amicroscope were evaluated. The overall prevalence of ID was 4.4%. The prevalence was lowest in virgin microdiscectomies (1.7%) and varied from 3.6% in decompression for spinal canal stenosis up to 14.5% in revision procedures. Of the overall 195 IDs, 127 occurred in primary surgeries and 68 in revision surgeries. In 107 primary surgeries, the individual surgical technique (InT) achieved asingle stage closure of the ID in 96procedures (89.7%). Among 20virgin surgeries, the ten-step technique (10ST) was successful in all cases (P = 0.21). Among 42 revision procedures following failed attempts to stop the CSF leakage, the InT achieved single-stage closure in 36procedures (85.7%), whereas after introduction of the 10ST, closure was successful in all 26cases (P = 0.03).

Portal venous deprivation in patients with portosystemic shunts and its effect on liver tumors

AimsTo outline the use of radiological investigations in patients with congenital portosystemic shunts (CPS) and to assess the degree of portal venous deprivation in relation to the development of liver tumors. MethodsSingle center retrospective cohort study of all patients with CPS referred from 1990 to 2016. Radiological investigations were reviewed for the presence of intrahepatic portal veins. Two groups were defined: Group 1 — without evidence of preservation of an intrahepatic portal venous system and, Group 2 — with evidence of intrahepatic portal venous flow. These groups were compared for the development of liver tumors, serum ammonia, and nature of subsequent surgical intervention. The ratio of infraceliac to supraceliac aortic diameter and hepatic enhancement in biphasic CT scans were also used to infer hepatic arterial in-flow and compared to age matched controls. Nonparametric tests were used throughout. A P value of 0.05 was considered significant. Data are quoted as median (IQR). Results45 patients (Group 1, n = 12: Group 2, n = 33) were investigated for CPS at a median age of 8 months (1 month–14 years). Liver tumors were more common in Group 1 than Group 2 [11/12 (92%) versus 10/33 (29%); P < 0.001]. Aortic ratio was significantly lower in patients with CPS compared to control (0.82 versus 0.96; P < 0.001), but there was no difference between patients with or without tumors (0.82 versus 0.82; P = 0.52). Enhancement of the liver parenchyma was greater in portal venous rather than arterial phases by a median difference of 28 (15–50) Hounsfield units in controls, compared to 15 (8.5–23.5) in CPS patients (P = 0.04). A single stage closure was possible in 2/6 (33%) operated patients in Group 1 and 14/20 (70%) in Group 2 (P = 0.32). ConclusionsPatients without radiological evidence of intrahepatic portal venous flow were significantly more likely to have associated hepatic tumors with a relative risk 3.1. Levels of evidenceThis manuscript includes data that are III and IV Levels-of-Evidence.

Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections.

Sternal wound infections after sternotomy are associated with high morbidity, high mortality, and prolonged hospital stay. The recurrence rate of sternal wound infections after single-stage closure is greater than expected. The aim of the study is to present our results of a consecutive series of Z-plasty for the treatment of recurrent sternal wound infections. Between March 2015 and March 2017, a total of 9 patients were referred to our clinic with a recurrent sternal wound infection due to sternotomy with or without osteomyelitis. All patients previously underwent one or more surgical procedures for sternal infection. Negative pressure wound therapy and several debridement methods were performed before reconstruction. Two triangular double-transposition fasciocutaneous flap techniques as Z-plasty under local anesthesia was performed for all of the patients. The flaps survived completely without any tissue loss. There were no major postoperative complications. One patient had recurrent infection after the flap procedure and was treated with antibiotic therapy. At 6months of follow-up, all of the patients were able to return to normal activities of daily living with a high patient satisfaction rate. Local sternal wound reconstruction is an effective, rapid, and simple with Z-plasty associated with low recurrence risk. We believe that Z-plasty can be used for recurrent local sternal wound infections as an alternative treatment option for selected patients without mechanical dehiscence.

Subunit Reconstruction of Mid-Facial Defects With Free Style Facial Perforator Flaps.

Reconstruction of facial defects is not only important for cosmesis but also for the function. Local flaps are considered the best reconstruction method for facial defects. The authors want to show the feasibility of free style facial perforator flap for the reconstruction of moderate sized mid-facial defects. Free style facial artery and lateral nasal artery perforator flaps were performed in 22 patients (11 males and 11 females) who had removal of facial tumor between March 2015 and December 2016 RESULTS:: The median age of patients was 62 years (range: 35-84). The mean follow-up period was 12.6 months (range: 5-24). Pathology results were basal cell carcinoma in 13 patients, squamous cell carcinoma in 6 patients, and other skin tumors in 3 patients. The defect size ranged from 2 × 2 to 5 × 5 cm. No major or minor complication happened but 1 flap had venous congestion that healed without any intervention CONCLUSION:: Free style facial perforator flaps are highly reliable flaps with wide range of motion. In addition, they provide single-stage closure with esthetic subunit reconstruction. With the current knowledge of reconstruction and skills of microsurgery, they can be easily the first choice for the closure of mid-facial defects.

Impact of oral clefts on the oral health-related quality of life of preschool children and their parents.

To assess the oral health-related quality of life (OHRQoL) of preschool children with cleft lip and palate (CLP) and their relatives. In this cross-sectional study, 55 2-5-year-old children with the history of CLP were randomly selected from those referred to Shiraz Lip and Palate Cleft Research Center and treated with single-stage closure (Push back palatoplasty). Furthermore, same number of children with the same age who attended the Shiraz School of Dentistry for routine dental care were selected as control group using randomized sampling. Children's demographic data were obtained from their parents. Farsi version of the Early Childhood Oral Health Impact Scale (F-ECOHIS) was used for evaluating these children's QoL. We found a significant difference in OHRQoL between children with CLP and children without CLP in the overall score of F-ECOHIS and all of subscales. In the impact on children subscale, the difference between these groups was remarkable in limitations' domain. As for difficulties faced by children, question on "difficulty in pronouncing words" had the highest average score. Furthermore, in impact on family, in parental distress domain, the difference between these groups was remarkable. For difficulties faced by family, financial impact got the highest average score. No significant difference was found between boys and girls with CLP in all subscales. While according to the score of total F-ECOHIS in unilateral and bilateral CLP children, there was statistically significant difference in these groups. Since oral clefts affect the QoL of children and their families even after the usual treatments, the implementation and maintenance of multidisciplinary interventional strategies are required for establishment of facial esthetics, oral function, and psychological support for such individuals.

Tracheocutaneous Fistula Closure with Turnover Flap and Polydioxanone Plate.

An alternative surgical treatment is proposed for closure of tracheocutaneous fistulas. The authors present a new technique for reconstruction of persistent tracheocutaneous fistula resultant from temporary tracheostomy. The single-stage closure under local anesthesia involves a fistulous tract turnover flap with a perforated 0.15 mm polydioxanone plate between the flap and the subcutaneous closure. This article presents 3 cases of persistent tracheocutaneous fistula treated by this method. At follow-up examination after follow-up, no recurrent fistula formation had occurred, and no respiratory deformity was present.

Use of Giant Bilobed Flap for Advanced Head and Neck Defects.

This article aims to review the use of giant bilobed flaps in the reconstruction of various large defects within the head and neck. A single case series study with chart review was performed. Various facial, neck, and mentum defects were documented, and closure was accomplished through a variety of medially and laterally based giant bilobed flaps. Preoperative and postoperative photography, as well as intraoperative planning, was performed. A total of 23 patients were able to achieve closure of facial, head, and neck defects with single-stage closure through the use of a giant bilobed flap. No tissue expanders, free tissue transfers, or skin grafts were required to achieve final closure, with acceptable cosmetic and functional results. Bilobed-shaped flaps allow for local tissue transfer in regions of otherwise limited tissue laxity and mobility, classically designed and utilized in the region of the nose. We describe its applicability to closure of large head and neck defects that may otherwise require free tissue transfer or the use of tissue expanders.

Incidental durotomy in spine surgery: first aid in ten steps.

Incidental durotomy (ID) is the most common complication of spine surgery. Revision procedures, ossification of the yellow ligament, or synovial cysts are well-known risk factors. The size, shape, and severity of ID are unpredictable, ranging from a pinpoint hole to a several centimeters large dural laceration with transected fibers following the slippage of a cutting burr. Furthermore, the occurrence of ID is always unexpected. Intra-operative management is often based on a steep learning curve rather than a structured scheme. To provide an intra-operative ten-step closure technique (10ST) for IDs of varying severity. A database of 4020 consecutive surgeries for lumbar degenerative disease over the past 4 years was searched for ID. The records of 176 patients were analyzed. Two dural repair techniques were compared: the "individual" technique (InT) and the 10ST. The overall prevalence of ID was 4.4%. The prevalence was lowest in virgin micro-discectomies (1.7%) and ranged from 3.6% in decompression for spinal canal stenosis up to 14.5% in revision procedures. All surgeries were performed with the aid of a microscope. Among 107 primary surgeries, the InT achieved a single-stage closure of the ID in 96 procedures (89.7%). Among 20 virgin surgeries, the 10ST was successful in all cases (P = 0.21). Among 42 re-do procedures following failed attempts to stop cerebrospinal fluid (CSF) leakage, the InT achieved single-stage closure in 36 procedures (85.7%). The 10ST was successful in all 26 cases (P = 0.03). The follow-up was 1 year. The 10ST should be considered for successful single-stage closure in primary repair of ID.

Single-stage repair of the anterior chest wall following sternal destruction complicated by mediastinitis

Although various techniques have been described, the ideal reconstructive procedure for treating massive sternal fragmentation and necrosis is still a matter of debate. Sometimes, reconstruction is so challenging that repetitive operations are required, particularly when complicated by mediastinitis and sternal osteomyelitis. Five patients (three males, two females, median age 66) with severe osteomyelitis and sternal destruction after receiving myocardial revascularization underwent partial or radical sternal resection, omental flap transposition, titanium mesh implantation and rectus abdominis muscle flap transposition. The final procedure involved single-stage closure. One patient died 9days after the final procedure due to pneumonia and septicemia. The other patients received antibiotics for at least 6weeks postoperatively. The mean hospital stay was 36days. Optimal wound healing was observed, with acceptable cosmetic disorders. Although lateral sternal support is the first-line surgical treatment for sternal dehiscence, performing primary closure of complicated defects is often impossible. Aggressive treatment modalities are required in such cases for anterior chest wall defects. This technique provides the ability to perform rigid and stable sternal closure in complicated cases.

Double-Opposing Rotation-Advancement Flaps for Closure of Forehead Defects

To describe a local flap for closure of forehead defects of all sizes that does not alter the brow position or hairline. Retrospective review of 16 cases in which the double-opposing rotation-advancement flaps were used for closure of small (<10 cm2), medium (10-20 cm2), and large (>20 cm2) forehead defects. This technique was developed from Orticochea's method for closure of large scalp wounds. All 16 patients underwent single-stage closure of forehead defects using our design. Six patients were men, 8 were women (mean age, 71 years). Preoperative defect sizes ranged from 3 to 30 cm2 (mean, 18 cm2). All wounds resulted from Mohs surgery for cutaneous malignant neoplasms; 2 were adjacent to previous reconstructions. No recurrence of tumor was seen during the study period. No permanent frontal branch injuries occurred. One patient developed a moderate cellulitis. Photographic analysis showed that brow position and hairline contour were maintained in all cases. The double-opposing rotation-advancement flap closure is a versatile reconstructive option for small, medium, and large forehead defects. The technique involves elevation of opposing, asymmetric flaps, with subsequent rotation of one side and advancement of the contralateral side. Single-stage closure may be accomplished without unappealing changes to the brow position or hairline.

The AIRNS flap: An alternative to the bilobed flap for the repair of defects of the distal nose

Defects of the distal nose and nasal tip are inherently challenging to reconstruct. Although the bilobed flap has a pivotal role for the closure of such defects to achieve a satisfactory outcome, it demands meticulous planning and execution. We sought to present our experience of the advancement and inferior rotation of the nasal sidewall (AIRNS) flap as a possible alternative to the bilobed flap for reconstruction of the distal nose. All patients who underwent AIRNS repair after Mohs tumor extirpation of the nose at 2 regional skin cancer units since April 2011 were reviewed. In all, 45 patients underwent the AIRNS flap repair. There were 25 men and 20 women, with a mean age of 70 years (range 41-88). The average defect size was 1.2 × 1.2 cm. The majority of cases involved the nasal tip. A single case of postoperative infection occurred in a smoker, which resolved without any long-term sequelae. No cases of flap necrosis or nasal airflow obstruction were seen. All cases produced good or excellent cosmetic results. Because of blunting of the superior alar crease, which may be avoided in a bilobed repair, the AIRNS flap is best avoided in laterally based defects of the nasal alar. The AIRNS flap is a reliable, single-stage closure option that, in our opinion, is simpler in design and execution compared with the bilobed flap and thus adds to the reconstructive surgeon's armamentarium when faced with centrally located defects of the distal nose.

WIDE PALATAL CLEFT – SINGLE STAGE OR TWO STAGE CLOSURE

Clefts of lip and palate presents a distressing blow to the family of the patient and their surgical correction a challenging task for the reconstructive surgeon. The patients affected with this deformity are handicapped by the psychological feeling of separation from the society in addition to the horror of a chain of surgeries and visits to the dental office. In addition to these single procedures requiring two stage approach add to the existing sequence further hampering the psychological well being of the patient. Closure of a wide palatal cleft often entails a two stage closure to ensure proper speech and functional outcomes to prevent future dehiscence of wounds leading to fistulae formation. This paper discusses the report of a patient reporting with wide palatal cleft of hard and soft palate treated by a single stage closure in an attempt to reduce the number of surgical procedures for the patient, resulting in a satisfactory treatment outcome considering the width of the cleft and age of the patient at the time of presentation.

Extensive calvarial exposure and full thickness sequestration following electrical burn injury presenting after one year: case report.

Background: Calvarial osteomyelitis is an uncommon complication of burn injury due to electricity.Patient: A case of electrical injury that progressed from full thickness scalp loss to calvarial osteomyelitis and sequestration of outer and inner tables seen after one year of calvarial exposure is presented.Result: The patient had calvarial sequestrectomy which exposed a four-centimetre diameter inner table defect, and a 13 cm diameter full thickness scalp and outer table defect. A single stage closure with Orticochea flaps and split skin grafts was achieved. There was an uneventful post operation course.Conclusion: Late presentation in electrical burn injury of the scalp complicated by calvarial loss has been managed without intracranial complications.Key words: electrical burns, calvarial exposure, sequestrectomy, late presentation

Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique

Background Closure of an enterocutaneous fistula and/or stomas in the presence of large abdominal wall defects is a challenging problem. In the present study, the results of the components separation technique are described. Methods All patients with an enterocutaneous fistula and/or stomas in the presence of large abdominal wall defects (ie, laparostomy of ventral hernia) who underwent a single-stage repair using the components separation technique in the period from January 2000 to July 2007 were reviewed retrospectively. Results A total of 32 patients were included. The median operating time was 204 minutes (range 87–573). In 18 patients, additionally to the components separation, an absorbable mesh was used. Postoperatively, in 16 patients 22 complications were reported. There were 9 patients with local wound problems. The median postoperative hospital stay was 12 days (range 5–74). Seven patients developed a ventral hernia. Four of them were small asymptomatic recurrences. Four out of the 15 patients with an enterocutaneous fistula developed a recurrent fistula. The median follow-up was 20 months (range 3–54). Conclusion Closure of enterocutaneous fistula and/or stomas and simultaneous repair of large abdominal wall defects is feasible using the components separation technique but morbidity is considerable. Early recurrence of abdominal hernia and fistula is acceptable.

O.434 Results of lip repair in patients with single-stage closure of unilateral cleft lip and palate

Introduction: The purpose of this study was to assess differences of the long-term results following surgical treatment in patients with cleft palate treated by two different surgical concepts.Patients: Fifty-nine adult patients operated on for cleft palate were examined. Thirty palates were closed by a two stage (Widmaier and Veau) and 29 by a single-stage procedure (Veau's pedicled flap).Methods: Lateral cephalometric and model analysis was performed. In the cephalometric analysis, the vertical and horizontal parameters of the position of maxilla and midface and transverse and sagittal dimensions of the models were compared between the two groups.Results: Model analysis: According to the Bolton analysis the maxillary dental arch was too large in 22 patients in each group. The other patients had mandibular arches that were too large. In 18 patients with two-stage closure and in 9 patients with one-stage closure, a space deficit in the lateral part of the maxilla was observed. Persisting transverse deficits were seen in all patients with two-stage repairs and in 11 patients with one-stage repairs. The deficit was more severe in the molar area in the first group and almost equally severe in the premolar and the molar regions of the second group. A sagittal deficiency was found more often in patients with two-stage repairs while Angle's class I occlusion was seen more often in patients with one-stage surgery. Lateral cephalometry: Similar SNA-angles were seen in both groups whereas the ANB-angle was greater following two-stage repair. In both patient groups a low inclination of the midface was seen. The vertical dimension of the midface in comparison with the lower face was normal in the one-stage group; in the other group a deficiency of the anterior midface height was registered.Conclusion: There was a more severe growth impairment of the midface in patients with this type of two-stage palatal repair. The horizontal deficiency was similar in both groups. The long-term occlusal result revealed smaller sagittal and transverse deficiencies in patients with this type of single-stage closure.

Repair of Bilateral Cleft Lip: Review, Revisions, and Reflections

Rarely does the appearance of a child with a repaired bilateral cleft lip compare favorably with that of a child with a repaired unilateral cleft lip. However, there has been a major change in operative strategy during the past decade, and as a result, the typical bilateral cleft nasolabial stigmata are no longer so obvious. The senior author restates the principles for correction of bilateral cleft lip and nasal deformity, and underscores the essential role of preoperative premaxillary positioning. He reviews his method of single-stage closure of the cleft primary palate, including three-dimensional adjustments based on predicted four-dimensional changes. Operative modifications are described for variations of bilateral cleft lip. The authors emphasize the surgeon's obligation for periodic assessment. In a consecutive series of 50 patients with repaired bilateral complete cleft lip/palate, the revision-rate was 33% as compared with 12.5% if the secondary palate is intact. No revisions were necessary for philtral size or columellar length. The authors propose that nasolabial appearance and speech are the priorities in habilitation of the child with bilateral cleft lip/palate rather than the traditional emphasis on maxillary growth.

Differences in cephalometric and occlusal outcome of cleft palate patients regarding different surgical techniques

Introduction: The purpose of this study was to assess differences of the long-term results following surgical treatment in patients with cleft palate treated by two different surgical concepts. Patients: Fifty-nine adult patients operated on for cleft palate were examined. Thirty palates were closed by a two stage (Widmaier and Veau) and 29 by a single-stage procedure (Veau's pedicled flap). Methods: Lateral cephalometric and model analysis was performed. In the cephalometric analysis, the vertical and horizontal parameters of the position of maxilla and midface and transverse and sagittal dimensions of the models were compared between the two groups. Results: Model analysis: According to the Bolton analysis the maxillary dental arch was too large in 22 patients in each group. The other patients had mandibular arches that were too large. In 18 patients with two-stage closure and in 9 patients with one-stage closure, a space deficit in the lateral part of the maxilla was observed. Persisting transverse deficits were seen in all patients with two-stage repairs and in 11 patients with one-stage repairs. The deficit was more severe in the molar area in the first group and almost equally severe in the premolar and the molar regions of the second group. A sagittal deficiency was found more often in patients with two-stage repairs while Angle's class I occlusion was seen more often in patients with one-stage surgery. Lateral cephalometry: Similar SNA-angles were seen in both groups whereas the ANB-angle was greater following two-stage repair. In both patient groups a low inclination of the midface was seen. The vertical dimension of the midface in comparison with the lower face was normal in the one-stage group; in the other group a deficiency of the anterior midface height was registered. Conclusion: There was a more severe growth impairment of the midface in patients with this type of two-stage palatal repair. The horizontal deficiency was similar in both groups. The long-term occlusal result revealed smaller sagittal and transverse deficiencies in patients with this type of single-stage closure.