Split Flap Research Articles

Split pedicle roll envelope technique around implants and pontics: a prospective case series study

Recreating a harmonious gingival contour for contiguous missing teeth in the anterior maxilla is challenging. The aim of this study was to evaluate a split pedicle roll envelope technique designed for pontics. Twelve patients presented a labial flat or concave profile at the implant and pontic sites before second-stage surgery. The contour deficiency was compensated with a palatal split pedicle flap with the implant part rolled into the labial envelope and the pontic part covering the denuded ridge. Interim restorations were screwed in to guide tissue remodelling. The labial convex profile (CPF) and facial mucosal level (FML) at the implant and pontic sites, the Jemt papilla index (PIS) in the different restorative environments, and peri-implant bone levels were recorded at baseline and at 1 week, 3 months, and 6 months postoperative. Results showed that the CPF had increased by 1.4mm at the implant site and 1.5mm at the pontic site at 6 months after surgery. PIS had increased by 2 at the implant–tooth/pontic–tooth sites and by 2.6 at the implant–pontic site. FML was coordinated with that of the contralateral teeth. All indices were favourable at 3 months and then remained stable. Within the limitations identified, this combined therapy can be considered as an alternative to achieve aesthetic success when contiguous maxillary anterior teeth are missing.

Incidences of malignancy in chronic burn scar ulcers: Experience from Bangladesh

Malignant transformation on any scar tissue is known as Marjolin's ulcer. Most cases of Marjolin's ulcer reported so far occur in post-burn scars but not all ulcers that occur in post-burn scar are malignant.One hundred and forty cases of chronic non-healing ulcers in post-burn scar were included in this prospective observational study. The study was conducted in the Department of Burn and Plastic Surgery Unit of Dhaka Medical College Hospital.Mean age of the patients was 40.63±18.44 with a range from 12 to 75 years. Two third of the patients were male. All patients underwent excision biopsy and coverage with either split thickness skin graft or flap. Histopathological analysis of the resected specimen revealed malignancy in 46 cases and pseudoepitheliomatous hyperplasia in four cases and verruca plantaris in one case. The rest of the cases were chronic non-healing benign ulcers. All 46 cases of Marjolin's ulcer were squamous cell carcinoma with a mean latency period of 26.73 years. The commonest site of chronic ulcer was in the lower extremities (n-80, 57%), and malignancy was also found to be more common there (n-18). The most common type of burn was flame burn (68.57%). The Marjolin's ulcers were significantly larger in size than benign ulcers, and were mostly exophytic or ulcerative in appearance whereas benign ulcers were mostly flat.A non-healing ulcer in a post-burn scar should be addressed promptly because of its potential to develop into a malignant ulcer. Emphasis should be given to early surgical treatment of deep partial to full thickness burns to prevent scar formation, particularly over joints, and thus reduce the risk of development of Marjolin's ulcer.

Split Latissimus Dorsi Muscle Flap Repair of Acquired, Nonmalignant, Intrathoracic Tracheoesophageal and Bronchoesophageal Fistulas

The development of a fistula between the tracheobronchial tree and oesophagus due to nonmalignant causes is uncommon. Division of the fistula with muscle flap interposition eliminates contact between the tracheobronchial segment and the oesophagus, theoretically decreasing the chance of recurrence as well as providing a robust blood supply to aid in healing. The split latissimus dorsi muscle flap is a well-suited flap for such repairs because of the ability to simultaneously cover two separate apertures (tracheobronchial and oesophageal). The authors describe the split latissimus dorsi muscle flap with step-by-step technique for repair of intrathoracic aerodigestive fistulas.

The Split Radial Forearm Flap for Lower Leg Defects

The conventional free radial forearm flap is a very reliable, long-pedicled flap with thin, pliable skin. These properties make it an excellent choice for high-risk reconstructions or defects requiring only a thin cover. The split radial forearm flap allows primary closure of the donor site and has a large variability in shape and size. In this report, the cutaneous perforators of the radial artery were investigated in fresh cadavers and we present our clinical experience with the split radial artery flap in 9 patients with lower leg defects. Sufficient perforators exist to safely divide the flap proximally and distally into segments. In all clinical cases, the donor site could be closed primarily. All flaps remained viable and 8 of 9 patients obtained an esthetically pleasing result. The split radial forearm free flap is an elegant option for reconstruction of small- to moderate-sized soft tissue defects in the lower extremity.

Split‐calvarial osteopericranial flap for reconstruction following endoscopic anterior resection of cranial base

To conceive and critically evaluate an adaptation of the split calvarial osteopericranial flap for reconstruction following endoscopic endonasal resection of the anterior skull base. Cadaveric anatomic study. Five cadavers were embalmed with methanol, and vasculature was injected with latex. Endoscopic endonasal resection of the anterior skull base was performed, followed by reconstruction with a unilateral osteopericranial flap and a contralateral conventional pericranial flap. Rigid reconstruction was achieved in all specimens. Osteoplastic flap harvest was made more reliable by drilling the diploe below the graft with a curved bur. Dimensions of the bony flap were ideally shorter and wider than the defect, allowing for flap inset and rigid support by the orbits without compromise of the flap vascular supply. Endoscopic inset of the flap is feasible via nasion-frontal osteotomy and inlay technique. Rigid anterior skull base reconstruction via split calvarial osteopericranial flap is adaptable to current endoscopic techniques. This provides more anatomic reconstruction than current methods and may lead to decreased complication rates following anterior skull base resection.

Reconstruction of complex soft-tissue defects around the knee joint with distally based split vastus lateralis musculocutaneous flap: A new technique

The aim of this study was to report our experience of using distally based spilt vastus lateralis musculocutaneous flaps for soft-tissue defects around the knee joint - a new technique. Cadaver dissection studies were conducted in three cadavers to demonstrate perforators entering the lower third of the vastus lateralis muscle arising from the superior lateral genicular artery. Its application in eight clinical cases for the reconstruction of soft-tissue defects around the knee joint is reported. Seven out of eight flaps survived well without any flap loss. One flap with a skin island measuring 12×20cm suffered a loss of 2cm distally. This was later treated with skin grafting. Six out of eight donor sites were closed primarily. Six patients achieved full functional range of motion by 3 months. One patient had a 10° limitation of knee extension. One patient had foot drop due to primary injury and walks with a limping gait. This flap is a new reconstructive option for knee defects. It can reach distally up to the tibial tuberosity and does not require an intraoperative change of position. The donor site can be closed primarily and is hidden inside the clothing. The function of the knee is not affected as the majority of the muscle is kept in continuity.

Total cheek resurfacing with split ascending neck flap: A new approach

BackgroundBurn scars and other forms of extensive cheek deformities are a tragedy for patients and pose a great challenge to surgeons due to limited availability of well-matching donor sites. The skin of distant regions and skin transplants contrasts with the facial skin. The most suitable site for tissue in cheek reconstruction is the neck, but this resource is limited. Cervical skin expansion is often complicated by tissue necrosis. A new approach (technique) for resurfacing the scarred cheek with a split cervical flap is presented in this paper. MethodsSixteen patients with extensive (covering more than half the area) cheek deformities (10 unilateral and 6 bilateral) were operated upon; ages ranged from 6 to 32 years old. First, the split neck flap is transposed on the cheek/cheeks, restoring the lower half; after stabilization of transferred tissues, the cervical flap on the cheeks undergoes balloon extension. Second, the cheek reconstruction is finished with an expanded neck flap. ResultsAxial flap circulation prevented tissue necrosis after the first stage of reconstruction. The cervical flap on the cheek tolerated the expander well. In all cases, the cheeks were resurfaced in full with optimally matching sensate skin posing no serious post-operative complications. Cervical skin on the face preserved its natural properties without soft tissue excess and donor site morbidity; neck and cheeks preserved normal contours. ConclusionGood cosmetic outcomes make this technique preferable for adults and children, and the technique is indicated as the first step for deformed cheek resurfacing for patients with uninjured neck.

Predictions of stability and control for a flying wing

The numerical simulation of a generic reduced radar signature tailless aircraft is considered. Investigation compares simulated data to low-speed wind tunnel experiments. Focus is on numerical predictions of steady longitudinal and lateral aerodynamics and influence of control surfaces on aerodynamic forces. Fully turbulent and transitional Reynolds Averaged Navier–Stokes (RANS) simulations predicted in agreement with experiment unstable pitch characteristics for low angles of attack (α), this was not the case for inviscid or laminar simulations. However, all simulations captured a sudden rapid increase in nose up pitch moment at higher angles of attack compared to experiments. Time accurate computations (URANS) captured non-linearity and unsteadiness in yaw moment with respect to differential split flap deflections for the studied angles of attack.

Airfoil morphing based on SMA actuation technology

Purpose – This study aims to develop an innovative actuator for improving the performance of future aircraft, by adapting the airfoil shape according to the flight conditions. The flap’s camber of a civil regional transportation aircraft’s trailing edge actuated and morphed with the use of shape memory alloys (SMA) actuator technology, instead of the conventional split flap mechanism is studied. Design/methodology/approach – For the flap’s members sizing an efficient methodology is utilised based on finite element (FE) stress analysis combined to analytically formulated design criteria. A mechanical simulation within an FE approach simulated the performance of the moving rib, integrating both aerodynamic loads and SMA phenomenology, implementing Lagouda’s constitutive model. Aim of this numerical simulation is to provide guidelines for further development of the flap. A three-dimensional assembly of the flap is constructed to produce manufacturing drawing and to ensure that during its morphing no interfer...

Assessment of marginal bone loss using full thickness versus partial thickness flaps for alveolar ridge splitting and immediate implant placement in the anterior maxilla

The aim of this study was to evaluate the effectiveness of maintaining the periosteal attachment of the facial and palatal cortical plates on crestal bone loss that occurs at the margin of dental implants placed immediately in split anterior maxillary alveolar ridges. This was a prospective randomized comparative clinical trial. The study population included 22 patients with edentulous anterior maxillary alveolar ridges who presented for treatment during the period March 2012 to September 2013. The selected patients were divided randomly into two equal groups. All patients underwent a maxillary ridge splitting technique; a total of 43 implants were placed immediately. A full thickness mucoperiosteal flap was performed in the control group patients, while a split thickness mucosal flap was done in the study group patients. Assessments included measurements of the linear changes in the marginal bone surrounding the implants immediately postoperative and after 6 months. Measurements were taken from cross-sectional and longitudinal cone beam computed tomography images using special software. The partial thickness flap used in the study group decreased the percentage of bone loss by 9.5% for the labial bone plate, 7.9% for the palatal bone plate, and 3.5% for the mesiodistal bone plate.

Increasing the Width of Keratinized Mucosa in Maxillary Implant Areas Using a Split Palatal Bridge Flap: Surgical Technique and 1-Year Follow-Up.

Sufficient soft-tissue coverage of maxillary implant sites may be difficult to achieve, especially after bone augmentation. The use of vestibular flaps moves keratinized mucosa (KM) toward the palate and may be disadvantageous for future peri-implant tissue stability. This study describes a new split palatal bridge flap (SPBF) that achieves tension-free wound closure and increases the KM width in maxillary implant areas. We began SPBF surgery with a horizontal incision in the palatal soft tissue to create a split-thickness flap. The second incision was performed perpendicular to the first, using a bridge design, at a distance of 10 to 15 mm. The superior layer can be moved crestally and sutured to cover the soft-tissue defect. The defect width was measured using a periodontal probe. The inferior layer was left exposed, and secondary wound healing created new KM in this region. This SPBF technique was performed on 37 patients. Of these, 16 patients were included in the assessment of clinical peri-implant outcomes. All of the SPBF procedures successfully resulted in a palatal regeneration of KM through secondary wound healing (mean regeneration width, 4.51 ± 1.17 mm; range, 3-6 mm). The 1-year follow-up of 16 patients revealed a mean pocket probing depth of 3.22 ± 0.6 mm with zero cases of peri-implantitis. The vestibular KM width at the involved implants was 2.82 ± 1.07 mm (range, 1.5-6 mm). Surgery for SPBF may be a promising technique for covering soft-tissue defects and increasing KM width in maxillary implant surgery.

Extensive keratinized tissue augmentation during implant rehabilitation after Le Fort I osteotomy: using a new porcine collagen membrane (Mucoderm).

The aim of this study was to test a new collagen matrix (Mucoderm) positioned during oral implant abutment connection. A patient previously treated with Le Fort I for bone augmentation and 8 implants showing minimal amount of keratinized tissue was selected for an extensive keratinized tissue augmentation and deepening of the oral vestibule by apically positioning a split palatal flap and palatal grafting with Mucoderm. Clinical data at 9 and 14 days and 1 and 2 months showed resorption of the collagen graft, augmentation of the keratinized tissue around the implants, and deepening of the vestibule, with minimal morbidity and reduced surgical treatment time. However, some vestibular keratinized tissue contraction was evident. The new collagen matrix may be a promising material as a substitute for an autologous gingival/connective tissue graft. Despite the preliminary results of this innovative article, before drawing any general conclusion, the benefit of the procedure should be further evaluated by prospective clinical trials.

Split Dorsal Rectangular Flap for Creating Web Space in Secondary Syndactyly Surgery

Split Dorsal Rectangular Flap for Creating Web Space in Secondary Syndactyly Surgery

Editorial referring to the paper published in this issue on pp. 202–207 Use of Martius flaps in complex female urethral surgery and the tethered vagina syndrome

Editorial referring to the paper published in this issue on pp. 202–207 Use of Martius flaps in complex female urethral surgery and the tethered vagina syndrome

Button-assisted Coronally Advanced Flap: An Innovative Ortho-perio Amalgamation

Introduction: Esthetics has become an essential criterion of the overall treatment plan in dentistry that comprises of a healthy and beautiful smile at any age. Multidisciplinary approach involving orthodontics and periodontics results in the maintenance of a beautiful smile and a healthy periodontium. The continuous endeavor for innovation of newer interdisciplinary treatment moda lities has resulted in the use of a passive object like the orthodontic button being used to provide the initial stabilization in cases of root coverage using a Coronally advanced flap (CAF). Objective: The objective of this case report is to evaluate the effectiveness of a new treatment approach which consists of coronally advanced flap (CAF) procedure combined with ortho dontic button application for the treatment of Miller’s class III recession defects. Methodology: After the application of orthodontic buttons in middle third of tooth surface, a split-full split flap was raised from tooth #22 to #24 and the flap was sutured 3 to 4 mm coronal to cementoenamel junction and the central part of flap was suspended with sutures to the orthodontic button to maximize the stabilization of the immediate postoperative flap location. Clinical parameters were recorded at 1 and 3 months postoperatively. Results: Complete root coverage was achieved when evaluated from baseline to 3 months along with gain in clinical attachment level and keratinized tissue. The final esthetics, both color match and tissue contours, were highly acceptable. Conclusion: Three months postoperative results showed that the CAF combined with orthodontic button is a very effective approach even in the treatment of Miller’s Class III recession defects.

The edentulous ridge expansion (ERE) technique an experimental study in the dog

To compare the healing and bony crest resorption at implants installed conventionally or applying an edentulous ridge expansion (ERE) technique in the maxilla. In six Labrador dogs, the first and second maxillary incisors were extracted bilaterally. In the left side of the maxilla (Test), the flaps were elevated and the buccal plate of the alveoli and septa was removed. After 3 months of healing, partial-thickness (split) flaps were dissected and the residual alveolar bone was exposed. In the right side of the maxilla, an implant was installed conventionally (Type IV; Control) while, in the left side, the ERE technique was adopted. Hence, an expansion of the buccal bony crest was obtained, and the implant was subsequently installed (Test). After 3 months of healing, biopsies were obtained and ground sections were prepared for histological analyses. A buccal vertical resorption of the bony crest of 2.2 ± 1.2 mm and 1.6 ± 0.7 mm was found at the test and control sites, respectively. The difference, however, did not reach statistical significance. The coronal level of osseointegration at the buccal aspect was located at 3.1 ± 1.0 mm and 2.2 ± 0.7 mm from the implant shoulder at the test and control sites, respectively, the difference being statistically significant. The mean values of the mineralized bone-to-implant contact (MBIC%) ranged from 43% to 48% at the buccal and lingual sites. No differences reached statistical significance. Implants installed by applying an ERE technique may osseointegrate similarly to conventional implant installation. However, vertical and horizontal resorption of the displaced buccal bony wall occurred as well.

Yaw Stability Analysis for UiTM's BWB Baseline-II UAV E-4

This paper presents a study about yaw stability analysis for UiTMs Blended-Wing-Body (BWB) Baseline-II E-4. This aircraft is equipped with split drag flaps in order to perform directional motion. One of the split drag flaps will be deflected to generate yawing moment. This yawing moment is generated through the drag that is produced upon deflection of flaps. The study was carried out using Computational Fluid Dynamics (CFD) for various sideslip angles (β) and various flaps deflection angle (δT). The simulation was conducted at 0.1 Mach number (35 m/s) and results in terms of coefficient such yawing and rolling moment are tabulated in order to determine the stability of the aircraft. The result reveals that the aircraft is directionally unstable. This is as expected because the aircraft does not have any vertical tail configuration to provide the yawing moment. However, high deflection of split flaps can still generate adequate restoring moment for the aircraft.

Plastic Surgery in Patients with Soft-tissue Infection

The purpose of the study To improve the results of the treatment of patients with purulent wounds through the development and introduction of a differentiated approach to the selection of skin plastic and reconstructive surgeries into clinical practice. Materials and methods The results of the treatment of 312 patients with purulent wounds of various etiologies were analyzed. The age of the patients ranged from 15 to 82 years. The wounds with the area of no more than 100 cm2 were observed in 152 (48,7%) patients, 100-200 cm2 - in 109 (34,9%), more than 200 cm2 - in 51 (16,3%) patients. The large size of the wound defect served as an indication for performing skin grafting. Results and their discussion We noted that if the area of the wounds was less than 100 cm2 , skin flaps were used (115 (75,7%) patients). For the area of the wounds between 100 and 200 cm2 , the use of split flaps prevailed (75 (68,8%) patients). For the wounds of more than 200 cm2 , plastic by split flaps was most commonly performed as the only possible form of the wound closure (24 (47,1%) patients) or in combination with plastic by local tissues (15 (29.4%) patients). Conclusion Full-thickness skin grafting can be used for the closure of the wounds that are located in the bearing areas as well as cosmetically and functionally important zones as well as during the recovery phase of the treatment of pressure ulcers, neurotrophic ulcers and deep frostbites. A differentiated approach to the selection of skin plastic and reconstructive operations allowed to achieve 91,4% short-term and 80% long-term positive results in the treatment of patients with surgical infection.

Use of the versatile sternocleidomastoid flap in oral and maxillofacial surgery: our experience

Our aim was to evaluate the reliability of sternocleidomastoid (SCM) flaps in the reconstruction of defects after oral and maxillofacial resections, and summarise the ways in which morbidity can be reduced. We retrospectively enrolled 65 patients who had malignant tumours resected, and assessed the postoperative viability of the SCM flap. All complications were recorded during a follow up period of 1–64 months. We also investigated the relation between recurrence in regional lymph nodes and their preoperative histological state. The conventional SCM flap, the split SCM flap with only the sternal head, and the SCM flap with a half-thickness clavicular graft, were used to repair different defects. No flaps necrosed completely, and in only 5 cases was there partial loss of the skin paddle. The skin paddle avulsed in 2 cases 2 patients developed wound infections. Only 9 patients developed complications (14%, 9/65). Use of the split SCM flap overcomes the problem of bulk. The combination of the SCM flap and clavicular bone enables early dental implantation. The SCM flap is convenient, reliable, and technically easy for the reconstruction of intraoral or mandibular tissue loss. Preservation of the branch of the superior thyroid artery and precise surgical technique contribute to a higher success rate.

Simplified bone-anchored hearing aid insertion using a linear incision without soft tissue reduction

Numerous techniques have been described to manage the skin and other soft tissues during bone-anchored hearing aid insertion. Previously, generally accepted techniques have sometimes led to distressing alopecia and soft tissue defects. Now, some surgeons are rejecting the originally described split skin flap in favour of a less invasive approach. To investigate bone-anchored hearing aid placement utilising a single, linear incision with either no or minimal underlying soft tissue reduction. Thirty-four adults were prospectively enrolled to undergo single-stage bone-anchored hearing aid placement with this modified technique. A small, linear incision was used at the standard position and carried down through the periosteum. Standard technique was then followed with placement of an extended length abutment. Patients were reviewed regularly to assess wound healing, including evaluation with Holgers' scale. Only 14.7 per cent of patients had a reaction score of 2 or higher. Most complications were limited to minor skin reactions that settled with silver nitrate cautery and/or antibiotics. None required revision surgery for tissue overgrowth, and there were no implant failures. Our results suggest this to be a simple and effective insertion technique with favourable cosmesis and patient satisfaction.