Split Flap Research Articles

Medial thigh flap: An eminent method of reconstruction of scrotal defect following fournier′s gangrene

Background and Objectives: Fournier's gangrene is a rare, rapidly progressive, fulminant form of necrotizing fasciitis of the genital, perianal, and perineal regions. It is characterized by progressive spread of necrosis in the skin and subcutaneous tissue which results in defects of various sizes in perineal region. Various techniques have been described for the reconstruction of these defects such as split thickness skin grafts, muscle flaps (e.g., Gracilis flap), and fasciocutaneous flaps (e.g., pudendal flap), perineal flap, anterolateral thigh flap, deep inferior epigastric perforator flap, and anteromedial thigh flap. We intend to study the results of medial thigh flap procedure in patients with scrotal defect following Fournier's gangrene. Materials and Methods: Medial thigh flap was performed in eight patients with Fournier's gangrene. The patients were selected consecutively from December 2016 to December 2017. All patients were followed for 3-6 months postoperatively. Results: All flaps survived well. However, in two cases, there was partial distal necrosis. Both cases were managed conservatively. In all cases, donor site healed well except for one case in which infection of the donor site suture line occurred. It was managed by frequent dressing. Interpretation and Conclusions: The medial thigh flap is a reliable fasciocutaneous flap which can be done in reasonably short operative time to cover difficult defects with excellent results.

Complete Philtrum Reconstruction on the Partial-Thickness Cross-Lip Flap by Nasolabial Muscle Tension Line Group Reconstruction in the Same Stage of Flap Transfer.

The blood supply pattern of the partial-thickness musculomucosal pedicle flaps is different from the traditional Abbe flap. The arterial blood supply and venous drainage are highly reliable during clinical practice. To describe the reconstruction of the philtrum in the cross-lip flap transfer using nasolabial muscle tension line group reconstruction. From January 1, 2014, through June 31, 2015, a total of 6 patients with upper lip defect were treated with philtrum reconstruction in the same stage of the split cross-lip flap transfer at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. These patients underwent reconstruction of the philtrum by nasolabial muscle tension line group reconstruction. The patients were compared with a randomly chosen group of 5 individuals without upper lip defects by measuring the 3-dimensional scans. In the patient group, the split flap was elevated from the posterior portion of the oris orbicularis muscle after the inferior labial arteries were divided. Then the partial-thickness flap was rotated 180° horizontally and inverted 180° upward to the upper lip defect. The philtrum was reconstructed using the nasolabial muscle tension line group reconstruction. Three-dimensional scans were performed from the 2-month to 28-month revisits. A total of 11 individuals were included in the study: 6 in the patient group (mean [SD] age, 17.0 [4.8] years; 2 [33.3%] female and 4 [66.7%] male) and 5 in the control group (mean [SD] age, 15.2 [6.0] years; 2 [40.0%] female and 3 [60.0%] male). In the patient group, 5 of 6 musculomucosal pedicle flaps were viable. A stable philtrum with philtral ridge and philtral dimple was reconstructed on the 5 flaps. The shape of the philtrum was natural according to the 3-dimensional scan measurement. One flap partially necrosed, and the scar retraction was severe postoperatively. The blood supply of the partial-thickness cross-lip flap was from the small vascular network of the lower lip. It is reliable to reconstruct a philtrum in this stage of flap transfer. A complete philtrum structure can be reconstructed by applying muscle tension on the flap. 4.

New insights into the cellular makeup and progenitor potential of palatal connective tissues.

The present study investigated the regenerative potential of connective tissues harvested from two palatal areas widely used as donor sites for muco-gingival surgical approaches. Connective tissue grafts (CTGs) were obtained by de-epithelialisation of a free gingival graft (deCTG) and by a split flap approach from a previous donor site (reCTG). Two types of mesenchymal stem cell (MSCs) were isolated and were named de-epithelialised MSCs (deMSCs) and re-entry MSCs (reMSCs). The cells were characterised and cellular functionality was investigated. CTGs were evaluated using immunohistochemical and ultrastructural approaches. No significant differences were observed regarding the frequency of colony-forming unit- fibroblasts, migration potential, and population doubling time between the two cell lines (p > 0.05). Both cell lines showed positivity for CD105, CD73, CD90, and CD44 and negative expression for CD34/45, CD14, CD79a, and HLA-DR. MSCs from both cell lines successfully differentiated into osteogenic, adipogenic, and chondrogenic lineages. Cells expressing antigens characteristic of CD34+ stromal cells (CD34+, αSMA-, CD31-) were traced in both CTGs. Ultrastructural analysis highlighted the presence of putative progenitors, namely fibroblasts,-in the pericapillary regions and in remote regions of the lamina propria- and pericytes-surrounding the capillaries. This study provides supplementary arguments for the use of CTG grafts in clinical practice due to the presence of putative progenitor cell. However, results were inconclusive regarding clinical decision-making to determine optimal harvesting area. Prior harvesting in the donor area did not appear to alter the regenerative capabilities of the connective tissue.

MUCOSAL FLAP VERSUS MUCOPERIOSTEAL FLAP IN RIDGE SPLITTING AND SIMULTANEOUS IMPLANT PLACEMENT USING PIEZOSURGERY (A RANDOMIZED CONTROLLED CLINICAL TRIAL)

INTRODUCTION: Ridge split procedures are commonly performed for horizontal widening-augmentation of narrow ridges which would otherwise preclude implant placement. Post-surgical vertical and horizontal crestal bone loss that might occur secondary to ridge splitting techniques present a serious obstacle to the success of implant placement and prognosis. OBJECTIVES: The evaluation of the effectiveness of maintaining the periosteal attachment of the buccal and lingual cortical plates to reduce and/or prevent crestal bone loss that might occur at the crestal margin of dental implants placed immediately in posterior mandibular alveolar ridges splitted using piezosurgery. MATERIALS AND METHODS: That was a randomized controlled clinical trial. The study population included 16 patients with edentulous posterior mandibular alveolar ridges. The sample was selected conveniently to fulfill a list of inclusion and exclusion criteria. Then the selected participants were allocated randomly into two equal groups each including 8 patients. A full thickness mucoperiosteal flap were performed in the control group patients, while a split thickness mucosal flap was done in the study group patients. All patients had undergone a mandibular ridge splitting technique using piezoelectrical surgical device. After ridge-splitting-porcedure implants with interpositional grafts were placed immediately. Assessments included measurements of the linear changes in the marginal bone surrounding the implants immediately postoperative as baseline, 3, 6 and 9 months postoperative. RESULTS: The statistical analysis of measurements obtained from both groups showed no significant difference between control and study groups regarding pain and edema assessment, while probing depth, and marginal bone level showed significant difference between both groups in favor to the study group. CONCLUSIONS: The ridge splitting technique using a partial thickness flap could be a successful option for the reduction of marginal bone loss around immediately inserted implants

Greater Omental Lymph Node Flap for Upper Limb Lymphedema with Lymph Nodes–depleted Patient

The greater omentum is supplied by the right, middle, and left omental arteries, which arise from the right and left gastroepiploic arteries. All or part of the greater omentum can be harvested based on this blood supply for free tissue transfer. It has stimulated new interest in its use as the donor site in the treatment of lymphedema. For patients who have failed other management options or have limited peripheral lymph node donor sites, the greater omental lymph node flap may offer the best chance for lymphedema treatment. We report a 59-year-old woman with a history of left breast cancer who was treated with left modified radical mastectomy and axillary lymph node dissection and developed left upper extremity Grade IV lymphedema. She received vascularized groin lymph node transfer and lymphaticovenous anastomosis, but the result was not satisfactory. She also had nasopharyngeal cancer that was treated with radiotherapy to the head and neck, making use of the submental lymph nodes flap impossible. Due to a lack of other options of lymph node donor sites, the split greater omental lymph node flap (GOLF) was used. After surgery, it showed an arm circumference reduction of 42.9% above the elbow and 36.4% below the elbow at an 8-month follow-up. There was no intraabdominal complication. The split GOLF has shown good results in a peripheral lymph node-depleted lymphedema patient. Using a laparoscopic technique for flap harvest has less risk of donor site morbidity and hides scarring.

Correcting the secondary bilateral cleft lip deformities using an innovative partial-thickness musculomucosal pedicle cross-lip flap

Objective According to the fine artery anatomy of the lower lip, we developed an innovative partial-thickness myocutaneous flap based on the vascular network of the submucosal and subcutaneous layers of the lower lip. We attempted to treat the secondary bilateral cleft lip deformities using this innovative cross-lip flap. Methods From July 2009 to June 2015, this new technique was used in 98 patients with secondary bilateral cleft lip deformities. The central defects usually occurred in these patients. The defects were reconstructed partially or completely according to the severities of the defects. The operative procedures were as follows: The split flap was elevated from the posterior portion of the oris orbicularis muscle after the inferior labial arteries were divided. Then the partial-thickness flap was rotated 180 degrees horizontally and inverted 180 degrees upward to the upper lip defect. Results All 98 musculomucosal pedicle flaps were viable. The upper lips were reconstructed according to the severities. Conclusions This myocutaneous cross-lip flap with musculomucosal-pedicle has a more reliable blood supply, better flexibility and plasticity. It is an effective method for aesthetic reconstruction for the secondary bilateral cleft lip deformities. Key words: Bilateral clefit lip; Secondary deformity cleft lip; Cross-lip flap; Upper lip deformity

Soft tissue augmentation around osseointegrated and uncovered dental implants: a systematic review.

The aim was to compile the current knowledge about the efficacy of different soft tissue correction methods around osseointegrated, already uncovered and/or loaded (OU/L) implants with insufficient soft tissue conditions. Procedures to increase peri-implant keratinized mucosa (KM) width and/or soft tissue volume were considered. Screening of two databases: MEDLINE (PubMed) and EMBASE (OVID), and manual search of articles were performed. Human studies reporting on soft tissue augmentation/correction methods around OU/L implants up to June 30, 2016, were considered. Quality assessment of selected full-text articles to weight risk of bias was performed using the Cochrane collaboration's tool. Overall, four randomized controlled trials (risk of bias = high/low) and five prospective studies (risk of bias = high) were included. Depending on the surgical techniques and graft materials, the enlargement of keratinized tissue (KT) ranged between 1.15±0.81 and 2.57±0.50mm. The apically positioned partial thickness flap (APPTF), in combination with a free gingival graft (FGG), a subepithelial connective tissue graft (SCTG), or a xenogeneic graft material (XCM) were most effective. A coronally advanced flap (CAF) combined with SCTG in three, combined with allogenic graft materials (AMDA) in one, and a split thickness flap (STF) combined with SCTG in another study showed mean soft tissue recession coverage rates from 28 to 96.3%. STF combined with XCM failed to improve peri-implant soft tissue coverage. The three APPTF-techniques combined with FGG, SCTG, or XCM achieved comparable enlargements of peri-implant KT. Further, both STF and CAF, both in combination with SCTG, are equivalent regarding recession coverage rates. STF + XCM and CAF + AMDA did not reach significant coverage. In case of soft tissue deficiency around OU/L dental implants, the selection of both an appropriate surgical technique and a suitable soft tissue graft material is of utmost clinical relevance.

Clinical application of free super-thin anterolateral femoral perforator lobulated skin flap with nerve for repair of tissue defect of the foot and ankle

Objective To explore the clinical outcome of free super-thin anterolateral femoral perforator lobulated skin flap with nerve for repairing the tissue defect of the foot and ankle. Methods Free super-thin anterolateral femoral perforator lob-ulated skin flap with nerve was transferred to repair soft tissue defects of the foot and ankle in 32 cases. There were 20 males and 12 females with an average age of 35.5 years(range, 21-50 years). The wounds located in dorsal and plantar ankle skin with ten-don, bone and/or internal fixation exposed. The defect area was from 12 cm×10 cm to 20 cm×15 cm. At first the site of perforator vessels were determined by Doppler, according to the wound shape and size, the flaps were designed and harvested with the site as center; the femoral lateral cutaneous nerve was carried and most tensor fascia was reserved. During flap harvesting trimming of the flap was carried out, the flap was freed and only connected with its vascular pedicle. A step-wise defatting was done from the periphery of the flap towards the vascular pedicle with 1.0 to 2.0 cm tissue around the perforator preserved. Flap circulation was carefully observed to prevent damage to the perforators. The vascular pedicle was disconnected and formed a split leaf skin flap, and then the flap was transferred to the foot and ankle to cover the defect. Results All the 32 flaps were survived. No vascular crisis happened and all skin grafts were survived in donor sites. Necrosis of 1.5 cm×1.0 cm of the distal flap occurred in 1 case five days after surgery and it was healed by dress changing. All the 32 cases were followed-up for 6 to 24 months(average, 13 months). The flaps were supple and elastic with near normal color. There was no bulkiness. Sensory function was recovered well and two point discrimination(2-PD)was about 3.0-5.0 mm. The function and appearance of the foot and ankle were good. According to the Chinese Medical Association of hand surgery upper limb function evaluation of upper limb, the results were excellent in 22 cases, good in 9, fair in 1, with 97%(31/32)overall excellent and good rate. Conclusion The free super-thin anterolateral femoral perforator lobulated skin flap with nerve is an improvement of the traditional anterolateral thigh flap. The survived flaps are ideal in terms of covering foot and ankle defects and restore function. Key words: Foot; Ankle; Surgical flaps; Soft tissue injuries; Microsurgery

Surgical management of Oral submucous fibrosis

Background: Oral submucous fibrosis (OSF), globally accepted as an Indian disease, has one of the highest rates of malignant transformation amongst potentially malignant oral lesions and conditions. The hallmark of the disease is submucosal fibrosis that affects most parts of the oral cavity, pharynx and upper third of the esophagus leading to dysphagia and progressive trismus due to rigid lips and cheeks. Nonsurgical measures like local steroids, hyaluronidase injections, vitamin supplements and jaw opening exercises have poor results. There lack of guidelines for choosing the surgical procedures. Methods: This prospective study was done on 13 cases of clinically diagnosed oral submucous fibrosis during 2012-2015. After diagnosis these patients are grouped according to the severity of the disease proposed by Chandramani More. The patients underwent either release and split skin grafting or Nasolabial flap or Superficial temporal artery fascial flap for intra oral cover. The results were analysed for postoperative mouth opening and complications. Results : Of the total 13 patients studied 8 were male and 5 females. The age ranged from 22 years to 68 year (Mean= 43 years). Preoperative functional stage was ten patients 15-25mm mouth opening (M3) and three patient <15mm mouth opening (M4) Mean preoperative mouth opening was 16.7mm. The procedure performed was release with split skin graft in six patients, release with Nasolabial flap cover in two patients and release with superficial temporal artery flap cover with graft in five patients. Mean post operative mouth opening was 35.6mma at follow up of 6 months. Conclusion : Surgical correction of oral submucous fibrosis offer better outcome than conservative management. The choice of surgical procedure depends on patient profile. Flap covers are better than split skin graft in term of recurrances. Nasolabial flap cover can be used in elderly with lax skin. The superficial temporal artery fascial flap cover has advantage of lesser morbidity and more suited in cases of severe restriction of mouth opening.

Management of post burn contracture of neck

Study Design: It is a prospective analytical study. Place and durations: Subjects &amp; methods: 43 patients admitted during JAN 2001 to DEC 2002 who presented with severe functional (25 patients) of cosmetic impairment (27 patients). We selected 4 different options to manage the patients. (1) Release of/or excision + thigh grafts (2) Release of/or excision + wolfm (3)Thick therish + local flap (4) Musculocutaneous flap. Results: Out of 43 patients 27 were females and 16 were male and the age varies from 4-45 years. Out of 28 patients a (1) 25 given satisfactory and excellent results, and 5 out of Six patients a (2) and 4 out of 5 with (3) gave excellent results. To evaluate the outcome of different options for the management of PBNC we are presenting our 2 years experience of PBNC Neck in 43 patients from January 2001 to December 2002 who were admitted through surgical outdoor of Teaching Hospitals of PMC, Faisalabad. In our set up most of the patients presented with severe functional (25 patients) and cosmetic impairments (27 patients out of 43) because of late presentation, delayed treatment, poverty and lack of proper medical facilities. We selected 4 different options to manage these patients accordingly i.e. (1) release or and excision of contracture and thick split skin graft, (2) release or and excision of contracture and full thickness skin graft, (3) thick split skin graft and local flap, (4) musculocutaneous flap, giving satisfactory to excellent results in 25 out of 28 patients, 5 out of 6 patients and 4 out of 5 patients respectively. Thick split skin grafting after release or/and excision of contracture with strict advice of wearing cervical neck collar remained our mainstay of treatment because it was one of the best practical options to deal with severe PBC Neck while other options being reserved for difficult and recurrent cases. Conclusion: Thick split skin grafting is an easy, cost effective, reliable and compliant to the patient. Furthermore thick split skin grafting is a simple procedure whi ch may be carried out by any general surgeon with reserve for referred for the difficult cases.

TREATMENT OF EXTENSIVE PURULENT-NECROTIC LESIONS OF THE LEG IN PATIENTS WITH NEUROPATHIC FORM OF DIABETIC FOOT SYNDROME

Актуальность. Развитие гнойно-некротических осложнений у больных с синдромом диабетической стопы (СДС) является причиной высоких ампутаций и ранней инвалидизации, что в свою очередь приводит к развитию метаболического синдрома и прогрессированию сердечно-сосудистых осложнений. В настоящее время способы лечения гнойно-некротических процессов при СДС направлены на сохранение опорной функции конечности. Наличие обширной гнойно-некротической раны голени – фактор риска появления показаний к высокой ампутации. Цель – разработка алгоритма лечения обширных гнойно-некротических ран голени у больных с нейропатической формой СДС. Материал и методы. В областном центре «Диабетическая стопа» на базе Видновской районной клинической больницы за период с 2009 по 2013 г. были проанализированы результаты лечения 62 пациентов с нейропатической формой СДС и наличием обширных гнойно-некротических ран голени. Всем больным проводилось хирургическое вмешательство, а также комплексная консервативная терапия. Лечение разделялось на несколько этапов: очищение раны до появления грануляционной ткани – выполнение аутодермопластики – стимуляция эпителизации. Эффективность лечения оценивали по срокам очищения раны, появления грануляций, эпителизации, количеству высоких ампутаций. Результаты. Больным выполнялись радикальные хирургические операции с пересечением путей распространения в проксимальном направлении гнойной инфекции с последующим открытым ведением раны. В последующем проводились этапные некрэктомии совместно с консервативной терапией, направленной на очищение раны. Средние сроки очищения раны составили 10,6±1,2 суток. Формирование грануляционной ткани происходило через 8,4±0,8 суток после первого оперативного вмешательства. При появлении очищенной грануляционной ткани пациентам выполнялась аутодермопластика свободным расщепленным лоскутом для стимуляции процесса эпителизации. Процесс эпителизации начинался через 10,2±0,6 суток. При поступлении, на 4-е и на 10-е сутки после первого оперативного вмешательства выполнялось измерение индекса лейкоцитарной инфильтрации. Нормализация этого показателя во время лечения свидетельствует об очищении раны и удовлетворительном течении раневого процесса. В период с 2009 по 2013 г. была выполнена одна (1,6%) высокая ампутация. Заключение. Активная хирургическая тактика, заключающаяся в иссечении первичного гнойного очага, пересечении гнойных проводящих путей (сухожилия, фасции), открытом ведении раны, последующих этапных некрэктомиях, в комплексе с консервативной терапией способствует максимальному очищению раны, снижению уровня интоксикации, активации репаративного процесса. Своевременное выполнение аутодермопластики ускоряет процесс эпителизации и заживления раны.

Surgical Management of Giant Genital Condyloma Acuminata by Using Double Keystone Flaps.

Condyloma acuminata in the external genitalia (genital warts) is a sexually transmitted disease that is often caused by human papillomavirus (HPV). We report a case of giant genital condyloma acuminata in a 35-year-old male patient with HIV comorbidity treated by wide surgical excision. Excision defect was covered with split thickness skin graft (STSG) and double keystone flaps. There was no complication after surgery. Ten months following surgery, there was no new condyloma lesion and the patient had normal voiding and erectile functions.

Definitive Management of Open Tibia Fractures Using Limb Reconstruction System

Open fractures are treated as surgical emergency and early administration of intravenous antibiotic coupled with early irrigation and debridement decreases the infection rate dramatically. Limb Reconstruction System (LRS) is a unilateral rail system which consists of Shanz pins, rail rods and sliding clamps. It is specifically designed to enable the surgeon to perform simple and effective surgery as it offers rigid fixation of fracture fragments, allowing early weight bearing and reduces economic burden. To determine the efficacy of Limb Reconstruction System for treatment of compound tibia fractures. A prospective study was carried out where in 54 cases out of 412 compound tibia fractures having Modified Gustilo Anderson Type IIIA and IIIB with a mean age of 42±5 years were treated using LRS over a period of 26 months. Limb reconstruction system was used in acute docking mode or with corticotomy and bone transport was done depending upon the bone loss. The soft tissue condition was assessed and split thickness skin grafting and flap repairs were done as per the need. Clinical and radiological assessment was done at every follow-up. Bony and functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. Among 54 patients, bony results as per ASAMI score were excellent in 36, good in 14, fair in 2 and poor in 2 patients. Functional results were excellent in 43, good in 7, fair in 4 patients. The average fracture union time was 8 months. Post-surgery patient satisfaction was excellent since fixation allowed weight bearing immediately. Average hospital stay was 7 days and financial burden was reduced by 40% as compared to multi staged surgery. The average time of return to work was 20 days. LRS is an easy, simple and definitive surgical procedure that allows immediate full weight bearing walking. It reduces hospital stay, is cost effective with excellent patient compliance and can also be used for bone lengthening/transportation.

Relative Composition of Fibrous Connective and Fatty/Glandular Tissue in Connective Tissue Grafts Depends on the Harvesting Technique but not the Donor Site of the Hard Palate.

Whether the composition of palatal connective tissue grafts (CTGs) varies depending on donor site or harvesting technique in terms of relative amounts of fibrous connective tissue (CT) and fatty/glandular tissue (FGT) is currently unknown and is histologically assessed in the present study. In 10 fresh human cadavers, tissue samples were harvested in the anterior and posterior palate and in areas close to (marginal) and distant from (apical) the mucosal margin. Mucosal thickness, lamina propria thickness (defined as the extent of subepithelial portion of the biopsy containing ≤25% or ≤50% FGT), and proportions of CT and FGT were semi-automatically estimated for the entire mucosa and for CTGs virtually harvested by split-flap (SF) preparation minimum 1 mm deep or after deepithelialization (DE). Palatal mucosal thickness, ranging from 2.35 to 6.89 mm, and histologic composition showed high interindividual variability. Lamina propria thickness (P >0.21) and proportions of CT (P = 0.48) and FGT (P = 0.15) did not differ significantly among the donor sites (anterior, posterior, marginal, apical). However, thicker palatal tissue was associated with higher FGT content (P <0.01) and thinner lamina propria (P ≤0.03). Independent of the donor site, DE-harvested CTG contained a significantly higher proportion of CT and a lower proportion of FGT than an SF-harvested CTG (P <0.04). Despite high interindividual variability in terms of relative tissue composition in the hard palate, DE-harvested CTG contains much larger amounts of CT and much lower amounts of FGT than SF-harvested CTG, irrespective of the harvesting site.

The Sternocleidomastoid Muscle Flap: A Versatile Local Method for Repair of External Penetrating Injuries of Hypopharyngeal-Cervical Esophageal Funnel.

A primary repair of external penetrating injury to hypopharyngeal-cervical esophageal (HP-CE) funnel without reinforcement has more complications if compared with muscle reinforcement. The aim of the present study was to assess the outcome of using sternocleidomastoid (SCM) muscle flap for reinforcement of primary repair of HP-CE funnel injury. The study proposed an algorithm for different uses of SCM flap repair according to site and size of funnel perforation. A prospective analysis of 12 patients, who had surgical treatment for external penetrating injuries of HP-CE funnel between January 2011 and September 2014, was recorded. The following factors were studied for each case: demographic data, Revised Trauma Score (RTS), mechanism of injury, time interval between injury and definitive surgical care, injury morphology, any associated injuries, technique of SCM flap used, length of hospital stay, and surgical outcome and complications. They were 10 males and 2 females and the mean age was 31.9 years. The cause of injury was stab wound in 5 (41.7 %) cases, gunshot injury in 4 (33.3 %) cases and 3 (25 %) cases after anterior cervical spine surgery. Isolated injury to HP and CE was recorded in 5 cases (41.7 %) for each site. However, 2 (16.7 %) cases had injury to both HP and CE. Cranially based SCM flap was mainly used in cases with HP injury and caudally based flap in CE cases with some limitations. The whole muscle flap was used in large (≥ 1 cm) defects while and the split muscle flap in small (<1 cm) defects. Oral intake started 7 days postoperatively with only one (8.3 %) case of small leakage, which was treated conservatively. The SCM flap is a very useful and versatile tool in reinforcement of HP-CE funnel injury with the advantages of high success rates of leakage prevention.

Versatility of the Medial Sural Artery Perforator Flap

INTRODUCTION: The medial sural artery perforator (MSAP) flap was first described in 2001.1,2 Having constant anatomy, long pedicle, and pliable soft tissue, the flap was shown to be a good alternative option for soft tissue reconstruction.3,4 The aim of this study was to report our experience with this flap for reconstruction throughout the body, highlighting its potentially increasing role as a workhorse flap for multipurpose reconstruction. PATIENTS AND METHODS: Between March 2006 and July 2014, the MSAP flap was used for reconstruction in 200 cases. The flap was transplanted as free (n=189) and pedicled (n=11). The sites of reconstruction included head and neck (n=129), upper extremity (n=47), and lower extremity (n=24). Patients’ charts were reviewed retrospectively. Indications, flap design, flap survival, and complications were analyzed. We further compared survival rate and complications between the three different reconstruction sites. RESULTS: In head and neck group, flap survival rate was 95.3%. There were fifteen re-explorations (venous congestion: 10, arterial occlusion: 4, both: 1) with 6 total failures due to unsalvageable congestion. The donor site was closed primarily in 85.3% of the cases. In upper extremity group, flap survival rate was 95.7%. There were five re-explorations (venous congestion: 2, arterial occlusion: 2, both: 1) with 2 total failures. The donor site was closed primarily in 76.6% of the cases. In lower extremity group, flap survival rate was 100% in free MSAP subgroup compared with 90.9% in pedicled MSAP subgroup. There was one re-exploration due to venous congestion salvaged successfully in free MSAP subgroup. Partial necrosis occurred in 2 pedicled MSAP flaps and managed by debridement and skin grafting. The donor site was closed primarily in 45.8% of the lower extremity cases. Versatile designs of the flaps included chimeric flaps with the gastrocnemius muscle (n=11) and split flaps (n=2). The plantaris tendon was transferred with the flap in 20 cases for composite reconstruction. CONCLUSION: The MSAP flap is an alternative workhorse flap for reconstruction of the head/neck and extremities. The flap can be harvested as free or pedicled. Multiple tissue components can be included with the flap for multipurpose reconstruction. A small to medium size flap should be harvested to ensure primary closure at the donor site, maximizing cosmesis and decreasing morbidity.

Bipaddled split pectoralis major myocutaneous flaps for single-stage immediate reconstruction of oral mucosal defects combined with neck defects in recurrent oral cancer patients

Bipaddled split pectoralis major myocutaneous flaps for single-stage immediate reconstruction of oral mucosal defects combined with neck defects in recurrent oral cancer patients

Summarized institutional experience of paediatric airway surgery

The management of paediatric airway stenosis is complex, and requires a dedicated team, consisting of thoracic surgeons, phoniatricians, logopaedics, paediatricians and anaesthetists. The majority of paediatric laryngotracheal stenosis is a sequela of prematurity and prolonged post-partal intubation/tracheostomy. Surgical correction is often difficult due to a frequent combination of glottic and subglottic defects. In 2012, the Laryngotracheal Program Vienna was launched. Since then, 18 paediatric patients were surgically treated for (laryngo-)tracheal problems. The median age of our patients was 26 months (range 2-180 months). Laryngotracheal stenosis extending up to the level of the vocal cords was evident in 9 patients. Three children were diagnosed with an isolated subglottic, and four with a short-segment tracheal stenosis or malacia. Two patients had a long-segment congenital malformation together with vascular ring anomalies. Five children were pretreated by rigid endoscopy before surgical correction, 12 of our 18 patients had a tracheostomy, 3 children were intubated at the time of operation. Different techniques of corrections were applied: laryngotracheal reconstruction (n = 4), extended partial cricotracheal resection (n = 4), cricotracheal resection with or without anterior split or dorsal mucosal flap (n = 4), slide tracheoplasty (n = 2), tracheal resection (n = 4). In 8 patients, a rib cartilage interposition was necessary in order to obtain a sufficient lumen enlargement and in 7 of these patients, an LT-Mold was placed to stabilize the reconstruction. We lost 2 patients, who were referred to our institution after failure of multiple preceding interventions, 2 and 3 months after the operation. Twelve patients are currently in an excellent condition, one is in an acceptable condition without a need for an intervention. Two patients required an endoscopic reintervention 18 and 33 months after the operation, 1 child is currently still cannulated. Paediatric airway surgery is complex, and requires a dedicated interdisciplinary team. An armamentarium of different resection and reconstruction techniques is necessary in order to achieve good long-term results.

Cranial vault expansion with the split bone flap technique in shunt-related craniosynostosis

Shunt-related craniosynostosis causing craniocerebral disproportion represents a particular complication of the treatment of hydrocephalus. When the modification of the shunt opening pressure does not improve the symptomatology, surgery for correction of craniocerebral disproportion is indicated. We present the results and advantages of the split bi-frontal bone technique that is a modification of the previous used frontal bone advancement technique. We retrospectively reviewed 5 patients with iatrogenic craniosynostosis treated in our institution from 1995 to 2012. A splitting bi-frontal bone flap that is left floating posteriorly was performed to increase the cranial volume. All patients were cured. This technique increases the volume of the skull favoring the expansion of the brain and allows good cosmetical results. No perioperative complications were reported. The fact that the brain has a more appropriate volume allows the disappearance of the clinical symptomatology related to the split ventricle syndrome. The advantage is the respect of the fronto-orbital shape in children and adults with the same results of the classic frontal advancement in terms of volume expansion. The study of cerebral blood flow confirms the increase of the cerebral blood perfusion and the improvement of the regional cerebral blood flow in borderline regions. We preconize, for the treatment of slit ventricle syndrome, the bi-frontal split technique in children and adults for its efficacy, the low rate of complications and the respect of aesthetical constraints.

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.