Small Flap Research Articles

A RARE CASE OF LOCALIZED DISSECTION OF SINUS OF VALSALVA DIAGNOSED BY MULTIMODALITY IMAGING

TOPIC: Cardiovascular Disease TYPE: Fellow Case Reports INTRODUCTION: Sinus of Valsalva dissection is extremely rare and life threatening. It commonly occurs after coronary intervention and can involve right or left sinus of Valsalva. We present a rare case of spontaneous localized dissection of sinus of Valsalva involving non-coronary cusp which was diagnosed with multi-modality imaging. CASE PRESENTATION: 65 year old woman with history of non-ischemic cardiomyopathy was admitted to the hospital for management of new onset atrial fibrillation with rapid ventricular rate. Rhythm control approach was opted after the initial rate control. Transthoracic echocardiogram showed left ventricular ejection fraction of 35% and moderate aortic regurgitation. Transesophageal echocardiogram performed to evaluate for left atrial appendage thrombus prior to cardioversion revealed an aortic dissection limited to sinus of valsalva. She underwent a CTA aorta which was negative for dissection. Cardiac gated MRI was performed to evaluate her aortic root which showed a small intimal flap with limited dissection of sinus of Valsalva at non-coronary cusp of the aortic valve. On review of images and history, the dissection was thought to be chronic and probably related to a diagnostic cardiac catheterization that was performed a month before her admission. After discussion with cardiothoracic surgery decision was made to medically manage the patient with serial imaging given her poor functional status and chronicity of the limited dissection. On one month follow-up patient remained stable and asymptomatic. DISCUSSION: Aortic dissection confined to sinus of Valsalva is a rare but life-threatening. The incidence of this has not been reported in literature. These cases are mostly diagnosed during pre-operative TEE or incidentally. Localized sinus of Valsalva dissections is easily missed on a CTA as the temporal and spatial resolution in these areas are compromised due to large vibrations by aortic valve. TEE is superior in diagnosing these types of dissections. Gated cardiac MRI can be helpful in some cases. CONCLUSIONS: Aortic dissection localized to sinus of Valsalva presents a clinical challenge in terms of diagnosis and management. High index of suspicion and multimodality imaging approach is often required to arrive at the right diagnosis. Given the rarity of this condition the guidelines on the management are limited. REFERENCE #1: Fukui T. Management of acute aortic dissection and thoracic aortic rupture. J Intensive Care. 2018;6:15. Published 2018 Mar 1. REFERENCE #2: Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases Eur Heart J. 2014;35(41):2873-2926. REFERENCE #3: Hiratzka LF, et al ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Catheter Cardiovasc Interv. 2010 Aug 1;76(2):E43-86. doi: 10.1002/ccd.22537. PMID: 20687249. DISCLOSURES: No relevant relationships by Shruti Hegde, source=Web Response No relevant relationships by Kalyan Potu, source=Web Response No relevant relationships by Omar Siddiqui, source=Web Response

Use of Inguinal Hernia Mesh (DynaMesh-ENDOLAP) in Immediate Implant-based Breast Reconstruction.

The rate of immediate implant-based breast reconstruction after mastectomy is increasing, and providing enough coverage for the implant is mandatory; however the choice of appropriate mesh for implant coverage is controversial. Considering the high cost and the limited availability of breast-dedicated meshes in our country, we conducted this study to investigate the consequences of using a polyvinylidene fluoride (PVDF) mesh designed for endoscopic and laparoscopic hernia repair (ENDOLAP) as a coverage for breast prostheses in breast reconstruction. A retrospective cross-sectional study was performed on data of patients who had underwent immediate implant-based breast reconstruction between 2012 and 2019. After skin sparing mastectomy and subpectoral implant insertion, the exposed lower and lateral parts were covered with the mesh. Seventy-nine reconstructions were performed on 62 patients. The average follow-up was 31.9 months (ranges 6-102 months). Postoperative complications including small flap necrosis (3.8%), seroma (8.9%), infection (5.1%), hematoma (3.8%), malposition (1.3%), rippling (1.3%), grade two and three capsular contracture (2.5%), and chronic pain (1.3%) occurred in 19% of the operated breasts. The complication rate requiring intervention was 5.3%, and no implant loss was observed. None of the patients who received radiation developed complications. ENDOLAP mesh is a cost-effective and safe option for implant coverage in immediate implant-based breast reconstruction, with an acceptable complication rate. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Numerical Simulation of Flow over Bionic Airfoil

In this study, the aerodynamic performance of bionic airfoil was numerically studied by CFD method. The bionic airfoil was represented by the combination of airfoil and a small trailing edge flap. A variety of configurations were calculated to study the effect of flap parameters, such as the flap angle, position, and shape, on the bionic airfoil aerodynamic characteristics based on two layouts which were that (1) there was a tiny gap between the airfoil and the flap and (2) there was no gap between the two. The results showed that the flap angle and position had significant effects on the aerodynamic performance of the airfoil with the two layouts. Compared with the clean airfoil, the maximum lift coefficients of the first layout and the second layout could be increased by 10.9% and 7.9%, respectively. And the effective angle of attack (AoA) range for improving the lift-to-drag ratio could reach 7°. The flap shape also affected the airfoil aerodynamic characteristics, and the flap with the sinusoid curve shape showed ideal performance.

Discovery of previously unrecorded goby Bathygobius cyclopterus (Valenciennes, 1837) (Perciformes: Gobiidae) from Jeju Island, Korea, inferred from mitochondrial DNA sequences

A single specimen of Spotted frillgoby, Bathygobius cyclopterus (Valenciennes, 1837), was collected from a tidal pool on Jeju Island, Korea, in October 2017. The species is characterized by five upper free rays of the pectoral fin, a lower jaw with a mental frenum with a slightly curved posterior margin, and a small flap on the anterior nostril. Mitochondrial DNA 12S rRNA revealed that it corresponds to B. cyclopterus than other congeneric species by 100% identity. This species is the third Bathygobius species of the fish fauna of Korea, and the new Korean name proposed for the species is “Eol-lug-mu-nui-mang-dug”.

Lotus petal flap for unusual indication: A recto-vaginal fistula with perineal defect after vaginal delivery.

Introduction and importanceThree to five percent of vaginal deliveries are complicated by third or fourth degree perineal laceration. Misdiagnosed perineal injuries may be associated with a poor sexual and psychological prognosis. Management of old perineal tears and laceration is challenging with a high failure rate. In such condition, interposition tissue technic or local flap can be a good surgical alternative. Lotus petal Flap, usually indicated in management of large perineal defect in gynecological oncology can be used.Case presentationWe report a case of 32-year-old women presenting complex and relapsed perineal fistula after vaginal delivery associated with perineal defect treated by lotus petal flap with a good outcome.DiscussionPerineal defects are commonly encountered after oncologic, traumatic or infectious perineal excisions and described as a challenging situation. In case of perineal defects after obstetrical tears, no validated surgical filler technics are recommended. Inspired from oncologic surgical technics to fill perineal defects, Lotus Flap can be used. Its advantages are to mobilize a satisfactory tissue volume to fill important perineal defect compared to the small bulbocavernous flap with a hidden scar comparing to gracilis muscle flap. This technic is associated with a good sexual and self-imaging outcome.ConclusionLotus petal flap may be required as a solution to manage perineal defect in case of perineal fistula. This technique provides aesthetic and good results for perineal reconstruction.

Hard-to-heal wound treatment medical devices: clinical trial protocol in Japan.

In consultation with academia and the Pharmaceuticals and Medical Devices Agency (PMDA), we have developed guidance for drafting protocols for clinical trials concerning medical devices for the healing of hard-to-heal wounds without ischaemia. The guidance summarises the validity of single-arm trials for hard-to-heal wounds, the definition of hard-to-heal wounds without ischaemia, methods of patient enrolment and clinical endpoints. This review focuses on the logical thinking process that was used when establishing the guidance for improving the efficiency of clinical trials concerning medical devices for hard-to-heal wounds. We particularly focused on the feasibility of conducting single-arm trials and also tried to clarify the definition of hard-to-heal wounds. If the feasibility of randomised control trials is low, conducting single-arm trials should be considered for the benefit of patients. In addition, hard-to-heal wounds were defined as meeting the following two conditions: wounds with a wound area reduction <50% at four weeks despite appropriate standards of care; and wounds which cannot be closed by a relatively simple procedure (for example, suture, skin graft and small flaps). Medical devices for hard-to-heal wound healing are classified into two types: (1) devices for promoting re-epithelialisation; and (2) devices for improving the wound bed. For medical devices for promoting re-epithelialisation, we suggest setting complete wound closure, percent wound area reduction or distance moved by the wound edge as the primary endpoint in single-arm trials for hard-to-heal wounds. For medical devices for improving the wound bed, we suggest setting the period in which wounds can be closed by secondary intention or a simple procedure, such as the primary endpoint.

Split Lateral Forehead Flap for Reconstruction of Upper and Lower Eyelids

Background: Eyelids reconstruction after tumor resection has be one of the most challenging procedures in reconstructive plastic surgery. Small defects may be closed by primary suture or covered by small local flaps or skin graft. But in large eyelids defects, we need to find a bigger source of color and texture matching tissue that will ensure functional and aesthetical outcomes. Many techniques have been described, but in this case, the author suggest a split lateral forehead flap designed to cover upper and lower eyelids. Patient and Operation Techniques: A Male 51 years-old-patient, presented himself in our clinic with a basal cell carcinoma involving the right upper and lower eyelids. The tumor had a history of 7 years, without any pain or vision disorders involved. Tumor was widely excised, leaving a full thickness on upper and lower eyelids. The inner lining palpebral was replaced by composite auricular graft following by lateral cantophexy. A lateral forehead flap raised with a right temporal pedicle, and the distal part of flap was split in half, and inset into the upper and lower eyelids defect. The donor region was closed with an STSG from Femur Dextra. After 14 days the flap was divided, the functional result was excellent. Discussion: At first, surgeons were worried of raising forehead flaps beyond the midline, fearing that by splitting the distal flap would cause its compropmise. However, rich anastomostic plexus exists between the major forehead angiosomes lined by the smaller calibre “choke” vessels. Conclusions: Periorbital Basal cell carcinoma resection may leave great defect to the underlying tissue. The need to provide adequate support to this structure requires complex techniques with minimum two flaps. In our case, we performed a split lateral forehead flap with a good functional and cosmetic outcome.

Post-Operative ischaemic stroke as a sequelae of unnoticed small internal carotid artery intimal flap

The risk of stroke associated with aneurysm coiling can occur as a result of thromboembolic complications. The iatrogenic internal carotid artery (ICA) dissection can also lead to ischemic stroke. A 42-year-old patient was diagnosed with a left ICA paraclinoid aneurysm. The endovascular coil embolisation was done. The aneurysm was completely obliterated with preservation of parent artery and distal flow. In the post-operative period, the patient developed a left middle cerebral artery territory infarct. The patient underwent decompressive hemicraniectomy and check data structures and algorithms (DSA) showed ICA dissection with no distal flow. The retrospective examination of earlier DSA revealed a suspected small intimal flap which later progressed to complete dissection and resulted in the infarct. We are reporting this case intending to emphasize careful examination of angiogram and findings suggestive of even a small intimal flap of ICA must not be overlooked. It might progress to frank dissection, stenosis of ICA and even fatal ischaemic stroke.

Elective open "Shield Tracheostomy" in patients with COVID-19.

PurposeTo prevent the consequences of long-term endotracheal intubation, patients undergo tracheostomies. However, as COVID-19 is highly contagious, its existence has made the tracheostomy a high-risk procedure. Tracheostomy procedures must, therefore, be adjusted for safety reasons. The aim is to present the adjustments that should be made to the surgical technique.MethodsBoth the medical charts and surgical reports of patients with COVID-19 who were subjected to elective open tracheostomies were reviewed.ResultsThe retrospective study included 25 patients. Our adjustments include the timing of tracheostomies, ideally putting them at 21 days after the onset of COVID-19, the advancement of an endotracheal tube to 26–28 cm from the upper-alveolar ridge, surgery being carried out in the intensive care unit with appropriately modified positions of the patient and providers, tracheo-cutaneous sutures, and intentionally making the small tracheal flap and the tracheal window the same shape as a medieval shield.ConclusionsA tracheostomy performed in this way is now referred to as the Shield Tracheostomy. Further improvements to the surgical technique are expected in the future.

Bursaphelenchus paraleoni n. sp. (Tylenchina: Aphelenchoididae) intercepted in Loblolly pine logs imported into China from the USA

Summary Bursaphelenchus paraleoni n. sp. was isolated from Loblolly pine, Pinus taeda, logs from the USA. The new species is characterised by a lateral field with three lines, 13-16 μm long stylet with small basal swellings, and the excretory pore located slightly posterior to the nerve ring. The male spicules are mitten-shaped, the lamina smoothly tapering towards the distal tip. The condylus is broadly rounded, with a small dorsally bent hook, rostrum triangular or conical with finely rounded tip, and cucullus absent. One midventral precloacal papilla, one adcloacal pair and two postcloacal pairs of genital papillae are present. The bursal flap is long and spade-like with the posterior margin truncate or irregular. Females have a small vulval flap 4-6 μm long, a post-vulval uterine sac extending for 34-49% of the vulva to anus distance, a very long tail with slight ventral curvature, mostly filiform and with a finely rounded terminus, occasionally bluntly rounded. Huge variation in the tails of males and females were observed in a culture. It is similar to species of B. eidmanni, B. leoni, and B. silvestris in the leoni-group but detailed phylogenetic analysis based on 18S, ITS and D2-D3 28S sequences confirmed it as a new species.

Bursaphelenchus parayongensis n. sp. (Tylenchina: Aphelenchoididae) found in packaging wood from China

Summary Bursaphelenchus parayongensis n. sp. was isolated from packaging wood of a consignment from China exported to Germany. The new species is characterised by the lateral field with three lines, 9-13 μm long stylet with small basal swellings, and the excretory pore located near the posterior part of metacorpus. The male spicules are mitten-shaped, the lamina smoothly tapers towards the distal tip. The condylus is broadly rounded, with a small dorsally bent hook, rostrum triangular with sharply pointed tip, and without cucullus. One precloacal papilla, one adcloacal pair and two postcloacal pairs of male papillae present, with the posteriormost pair forming ‘gland papillae’. Bursal flap long, spade-like with posterior margin truncate or irregular. Females have a small vulval flap of 2-3 μm long, and a post-vulval uterine sac extending for 55-77% of the vulva to anus distance. Tail cylindrical, mostly (about 70%) with a robust mucron, very short to less than 3 μm, but occasionally tail terminus bluntly rounded, without mucron. It is similar to species in subgroup 3 of the eggersi group including B. carpini, B. clavicauda, B. cryphali and B. yongensis, but morphologically different. Detailed phylogenetic analysis based on partial 18S, ITS and D2-D3 region of 28S sequences has confirmed the status of this nematode as a new species.

The application of a 70° endoscope in performing transcanal middle ear surgery.

Endoscopes increase the expediency of transcanal middle ear surgery. However, the application of a 70° endoscope is limited and seldom discussed, mainly because of its large angle. We introduce our experiences with the 70° endoscope in transcanal middle ear surgery. This is a retrospective chart review of 127 patients with chronic otitis media who underwent middle ear surgery performed by the senior author in 2016 at a tertiary referral center. The types of eardrum perforation were classified as central, inferior, posterior, or anterior according to the main location of the hole. The demographics, surgical pictures, and operative records were reviewed. In 15 ears of the 127 patients, the ossicles were recognized directly by a microscope. In another 112 ears, the ossicles could not be identified under a microscope. Without elevating the tympanomeatal flap, the ossicles could be recognized in 72 of these 112 ears with endoscopes, especially the 70° endoscope. In 35 of these 112 ears, an incision to extend the drum perforation or creation of a small tympanomeatal flap in the posterior-superior canal was made to observe the ossicles. However, 5 of these 112 ears were still noted to have a narrow and/or curved ear canal and preoperatively needed to undergo endaural incisions. Among the other 122 patients who first underwent attempted transcanal surgery, 15 ears changed to endaural incisions. The drum perforations were repaired directly through the perforation in 107 ears via the transcanal route. One year after surgery, the air-bone gap closure was 16.0 ± 11.8 dB, and the graft take rate was 91.3%. With the help of a 70° endoscope, we can use the transcanal transperforation route to evaluate and reconstruct drum perforations and ossicular chains in appropriate patients. Hence, normal tissue injuries to the ear canal can be minimized.

Risk Factors for Plate Extrusion After Mandibular Reconstruction With Vascularized Free Flap

Plate extrusion after mandibular reconstruction is a complication that imposes significant morbidity on the patient. The goal of this study is to estimate the incidence of plate extrusion after mandible reconstruction with a vascularized free flap and to identify the factors associated with plate extrusion. This was a retrospective cohort study involving patients who underwent mandibular reconstruction from October 2008 to July 2019 at LAC+USC or Keck Hospital of USC. Inclusion criteria were age ≥ 18 years, single-stage mandibular reconstruction with vascularized free flap, and follow-up of at least 12months. Relevant demographic, intraoperative, and postoperative data were collected. The primary outcome was postoperative plate extrusion within the 12-month follow-up. Descriptive, univariate, and multivariate analyses were performed. Statistical significance was set at P≤.05. A total of 102 patients were included in this study. The majority received a fibula free flap (90%) for a malignant neoplasm (76%). All patients had at least 12months of follow-up. The rate of plate extrusion was 16%, with the majority of those patients undergoing plate removal (69%). After adjusting for postoperative fistula, soft tissue, and length of hospitalization, we found that any history of smoking (odds ratio= 12.8; confidence interval, 1.57 to 104.2), number of osteotomies (odds ratio 3.07; confidence interval, 1.09 to 8.6), flap nonviability (odds ratio= 18.2; confidence interval, 2.22 to 148.8) were associated with plate extrusion on multivariate analysis. Postoperative soft tissue infection approached significance. This study demonstrates that smoking history, number of osteotomies, and flap nonviability are associated with plate extrusion after mandible reconstruction. Performing fewer osteotomies when possible to avoid excessively small flap bone segments and minimizing postoperative complications may improve long-term outcomes after mandibular reconstruction.

Mucosal Grafting Reduces Recurrence After Endonasal Surgery of Petrous Apex Cholesterol Granulomas.

The endoscopic endonasal approach (EEA) is increasingly utilized for management of petrous apex cholesterol granuloma (PACG). Surgical goals include drainage and marsupialization of the cyst. Various techniques have been described to try to reduce the rates of recurrence. We studied the effect of mucosal grafting on recurrence. Retrospective Cohort study. Patients who underwent EEA for PACG at two tertiary care centers between 1999 and 2018 were identified and divided into two cohorts: Mucosal versus no mucosal reconstruction. Surgical approach, reconstructive method, and recurrence were recorded. Primary endpoint was symptomatic or radiographic recurrence. Thirty-four patients were identified undergoing 37 surgeries. Four patients developed recurrences of which three elected to undergo revision. Some form of mucosa was used to line the drainage tract in 20 cases. A free mucosal graft was used in 8, and a small customized nasal septal flap (miniflap) in 12. All four recurrences occurred in cases where no mucosa was used, demonstrating decreased recurrences with mucosal reconstruction (P< .05). There was no difference found between free mucosal grafts and miniflaps. Utilization of mucosa to partially line a circumferentially de-epithelialized drainage pathway after EEA for PACG reduce recurrence rates. 3 Laryngoscope, 131:E2513-E2517, 2021.

Description of Bursaphelenchus microcarpae n. sp. isolated from Cryphalus abbreviatus emerged from Ficus microcarpa, with a report of B. carpini re-isolation

Summary Two Bursaphelenchus spp. belonging to the eggersi group (subgroup 3) were isolated from bark beetles (Cryphalus spp.). One species, isolated from Cryphalus sp. cf. carpini that emerged from a log of an unidentified broad-leaved tree (considered to be Carpinus sp.) collected in Sugadaira, Nagano, Japan, was identified molecularly and typologically as B. carpini. The other species, isolated from C. abbreviatus that emerged from a dead log of Ficus microcarpa collected in Okinawa, Japan, was differentiated molecularly from other eggersi group species. The new species is characterised by its three-lined lateral field, seven genital papillae with the posteriormost pair forming ‘glandpapillae’, short and stout male spicule with a strongly dorsally recurved and pointed condylus, small and rectangular male bursal flap with a variable terminus, female vulva with a ‘side flap’, broadly rounded female tail tip and molecular sequences of the ribosomal RNA region and partial mtCOI gene. The species is described and illustrated herein as B. microcarpae n. sp.

Morphological and molecular characterization of Paratylenchus beltsvillensis n. sp. (Tylenchida: Paratylenchidae) from the rhizosphere of pine tree (Pinus virginiana Mill) in Maryland, USA.

The pin nematode, Paratylechus beltsvillensis n. sp. collected from rhizosphere soil of a Virginia pine tree (Pinus virginiana Mill) growing in Little Paint Branch Park, Beltsville, Prince George’s County, Maryland, USA, is described and illustrated along with light and scanning electron photomicrographs. Females, males, and juveniles of this new species were recovered from soil samples using the sugar centrifugal flotation and Baermann funnel extraction methods. Morphologically, females are short, body length ranging from 245 to 267 μm, stylet from 70 to 75 μm long with anchor shaped knobs, vulva located at 70–73% and small vulval flap, spermatheca large, and ovoid filled with sperms. Lateral field with three incisures, of which the outer two are prominent. Tail slender, having a rounded tail terminus. Males without stylet and have a degenerated pharynx, spicules = 17–20 µm and gubernaculum = 5.0–5.5 µm. Both morphological observations and molecular analysis of ITS and partial 28S ribosomal RNA gene sequences indicated that the specimens collected from the soil at Beltsville Park from rhizosphere soil samples from Virginia pine represents a new pin nematode species.

506 Uneventful pseudoaneurysm of the ascending aorta with sternal erosion in pregnancy

Abstract A 36-year-old woman at 31 weeks’ gestation presented with exertional dyspnoea and palpitations. She had a history of bicuspid aortic valve treated with surgical aortic valvotomy for severe stenosis, followed by ascending aorta replacement for type A acute aortic dissection and Bentall operation with a mechanical valve for severe aortic regurgitation. Eight years after the last surgery, magnetic resonance angiography showed aortic arch aneurysm (49 mm) with a small intimal flap. Thereafter, the patient was lost to follow-up until the current admission. She was hemodynamically stable on presentation and physical examination was unremarkable apart from a mechanical second heart sound. The electrocardiogram showed sinus rhythm with left bundle branch block (Panel A). Transthoracic echocardiography revealed severe left ventricular dilation (EDV 90 ml/m2) with mild dysfunction (EF 50%), normal prosthetic aortic valve function, and aortic arch dilation (50 mm) (Panel B and C). After a multidisciplinary evaluation, elective cesarean section was performed at 34 weeks’ gestation. A post-delivery aortic computed tomography angiography revealed aortic arch aneurysm (52 mm) with intimal flap and two pseudoaneurysms of the anterior aortic wall causing sternal erosion (Panel D, E, F and G). Subsequently, the patient underwent ascending aorta and aortic arch replacement by Frozen Elephant Trunk technique with a 24 x130 mm prosthesis between the aortic root and the descending aorta. The postoperative course was uneventful, and the patient was discharged to a cardiac rehabilitation centre.

Refinements of the medial femoral condyle bone flap for finger reconstruction

• Small size bone flaps are viable and effective in hand bone defects' reconstruction. • Medial femoral condyle (MFC) bone flap is relatively easy and fast to harvest; the donor site has relativelo low orbidity. • Medial femoral condyle (MFC) bone flap may be used as flow-through flat for digital revascularization.

Repair of Donor Site Defects After Forearm Free Flap Harvest With Dual Triangular Flaps and in Situ Small Full-thickness Skin Flaps.

The aim of this study was to introduce a method for repairing donor site defects after harvesting forearm free flaps with dual triangular flaps combined with in situ small full-thickness skin flaps. Free forearm skin flaps were applied to repair defects after tumor resection in 25 patients with oral squamous cell carcinoma. Although forearm free flaps were prepared, dual triangular flaps and adjacent full-thickness skin flaps were designed and fabricated to repair donor site defects in situ. Twenty-five cases of forearm donor site defects were successfully repaired with dual triangular flaps combined with in situ small full-thickness skin grafts. All adjacent full-thickness skin grafts used to close the donor site defect of the forearm survived, and the wound healed well without delayed wound rupture or serious complications at the donor site. The movement of the elbow and wrist joint on the side of the flap was normal, the blood supply in the palm was normal, and the skin color at the donor site of the forearm skin flap was similar to that of the surrounding tissue. There was no dent deformity or contracture deformity. Moreover, there was no significant difference in swelling and wrist movement between the adjacent forearm skin grafting group and the abdominal skin grafting group, but the former technique reduced the risk of scar infection and tendon exposure and greatly improved the esthetics of the surgical site on the forearm. Modified donor dual triangular flaps combined with adjacent full-thickness skin grafts can reduce the recovery time during and after surgery and avoid trauma at a third surgical site. This method is worthy of practical application in the preparation of forearm skin flaps for oral and maxillofacial surgery.

Comparative Evaluation of Suture Versus Sutureless Surgery in Mandibular Third Molar Impactions.

The purpose of this study is to compare the suture versus sutureless surgery in impacted mandibular third molar and to evaluate the morbidity and complications associated with each technique. A total of 50 patients with asymptomatic impacted mandibular third molars were randomly divided into two groups of 25 patients each. Radiographs were taken to assess the angulation and degree of eruption in the third molar. A small modified Szmyd, V-shaped flap was raised in all cases, and teeth were extracted. In Group I-Suture group (suture was used to close the flap), and in Group II-Sutureless group (no suture used to close the flap). The post-operative pain, swelling, trismus, haemorrhage, periodontal pocket, and alveolar osteitis were evaluated at 24h, 48h, 5th days, 7th days, and 2weeks after surgery. The statistical analysis was done using the Chi-square "t" test and Independent Samples "t" test. Pain, swelling, and trismus were found to be significantly reduced especially in the immediate post-operative period in the sutureless group as compared to the suture group (p < 0.001). There were no incidences of intra-operative and post-operative haemorrhage in any case. Follow-up of all the patients showed that there was no difference in periodontal sequelae and alveolar osteitis. Sutureless surgery with small flap was found to be less invasive, time-saving, and also a cost-effective method. This technique significantly reduced the early crucial phase of patient discomfort and demonstrates good results.