Standard Flap Research Articles

Breast Cancer Patient Flap Management after Mastectomy: A Best Practice Implementation Project

BackgroundBreast cancer is a prevalent malignancy in women, with mastectomy as the main surgery. Common post-mastectomy complications are seroma (15%-81%), infections (2.9%-3.8%), and flap necrosis (10%-18%), severely impacting quality of life and costs. Howerever, there's a lack of standardized flap care protocols and limited staff knowledge. ObjectivesThis study aims to apply best evidence for flap management post-mastectomy to standardize practices, reduce complications, and enhance patient's quality of life. MethodsThis project followed JBI PACES and GRiP principles, implementing evidence-based practices in a Chinese tertiary hospital between January and May 2023. It entailed evidence identification, integration into clinical context, protocol development, baseline audits, barrier/enabler analysis. The study compared pre- and post-evidence implementation rates of flap complications, healthcare staff's knowledge/skill scores on mastectomy flap management, and audit indicator adherence by both staff and patients. ResultsAfter evidence application, flap ischemia/necrosis rates dropped from 8.57% to 5.56% (P<0.001), wound infection rates after surgery reduced from 5.71% to 2.78% (P<0.001), and seroma rates decreased from 17.14% to 2.78% (P<0.001). Healthcare staff's knowledge and skill scores for flap management following mastectomy increased from 50.67±18.32 pre-implementation to 98.33±4.01 (t=-13.90, p<0.001). Audit criterion compliance rates increased from 8.57% to 94.29% to between 91.67% and 100%, with statistically significant differences in all 15 criteria (P<0.001). ConclusionsEvidence-based management of flaps after mastectomy improves healthcare staff's knowledge and skills, enhances nursing quality, effectively reduces flap complications in patients, and boosts their quality of life. micro abstractThis study implemented evidence-based practices for post-mastectomy flap management at a Chinese tertiary hospital, reducing complications: flap ischemia/necrosis from 8.57% to 5.56%, infections from 5.71% to 2.78%, and seroma from 17.14% to 2.78%. Healthcare staff's knowledge and skills improved significantly, boosting compliance with audit criteria. Results indicate enhancements in nursing quality and patient quality of life.

Cyanoacrylate versus suture as flap closure methods in mandibular third molar surgery: a split-mouth randomized controlled clinical study.

Sutures have been the standard flap closure method of choice following mandibular third molar surgery but can lead to some complications. Tissue adhesives, including cyanoacrylate, have emerged as alternative flap closure method in this surgery to overcome such drawbacks. However, limited clinical trials can be found. Therefore, the aim of this clinical study was to compare two methods of flap closure in mandibular third molar surgery, cyanoacrylate and 4/0 silk sutures, by assessing post-operative outcome measures (pain, swelling, trismus, and healing) and patient-reported outcome measures (PROMs). A randomized split-mouth clinical trial was designed, in which mandibular third molar (M3M) extractions were performed, where the control side flap was closed with 4/0 silk sutures and the test side flap with cyanoacrylate. Swelling, pain, trismus, healing, and PROMs were recorded post-operatively. These variables were analyzed by means of the nonparametric Mann-Whitney U test, using SPSS statistical software version 28.0.0 (IBM® SPSS®, Chicago, IL, USA). For all results, a 95% confidence interval was recorded (significance level p < 0.05, two-tailed). A total of 17 patients were recruited and 34 mandibular third molar extractions were performed. No statistically significant differences were found in terms of swelling, pain, trismus, healing, and PROMs between both groups (p<0.05). No statistically significant differences were found between flap closure with 4/0 silk sutures and cyanoacrylate, in terms of surgical post-operative outcomes and PROMs. However, further studies with larger sample sizes are required to be able to affirm it with greater certainty.

A quilting sutures technique for flap closure in patients undergoing modified radical mastectomy for the prevention of seroma: A single-center, randomized controlled trial.

Seroma formation is a common adverse event following modified radical mastectomy, and it leads to delayed wound healing and increased post-operative pain and increases overall morbidity of patients. The quilting sutures as a newer technique for the skin flap closure is done to reduce incidence of seroma formation. Although it has controversy in the literature for the satisfactory outcome, the study has aimed to compare the Quilting suture technique with the conventional closure method to evaluate the efficacy of the quilting technique. The primary objective of the study was to access and compare the frequency of seroma formation following the quilting suture technique with standard flap closure in MRM. The secondary objectives were to compare drain output, post-operative complications, and the requirement of additional procedures for management of related complications. The 72 female participants in this randomized control trial had modified radical mastectomy after being diagnosed with breast cancer. The quilting suture technique was applied in the 36 patients and conventional technique applied in 36 patients for skin flap closure. The frequency of seroma formation and other complications were reported. Between the two groups, there was no statistically significant difference in the frequency of seroma production (P = 0.233). Total drainage volume (P = 0.213), drainage duration (P = 0.652), and post-operative complications (P = 0.641) did not substantially differ between the two groups. The study concludes that the quilting sutures technique does not decrease the incidence of seroma formation, total drain output, and total duration of drainage. There is no significant difference in complications and requirement of additional procedures compared to the standard technique.

Evaluation of the predictive value of the body-mass-index choosing perforator flaps from different donor sites

BackgroundFree flap design must fulfill different criteria to ensure functional and aesthetic reconstruction of different types of defects in different body areas. A four-dimensional planning concept was used including flap length, width, thickness and tissue composition. This study evaluates if body-mass-index (BMI) has a predictive value for flap design.MethodsA prospective study including hospitalized patients in the Department of Plastic, Aesthetic, Hand and Reconstructive Surgery was conducted. Not taking into account the reason for admission, the patients were examined based on age, weight, height, BMI and sex. The areas of a potential harvest of free fasciocutaneous and perforator flaps were measured using ultrasound examination to determine the thickness of the subcutaneous layers and prove blood perfusion.ResultsOver the period of four months, a total of 101 patients (36 females and 65 males) were included in this study and gave written consent. No statistical significance regarding the demographic data such as age, sex and BMI could be identified. An average to high correlation between free flap thickness and BMI was shown for the thoracodorsal artery perforator (TDAP), anterior lateral thigh (ALT) and deep inferior epigastric perforator (DIEP) flap in both, male and female patients.Free flaps of distal body parts such as the interosseous posterior flap, showed a lower correlation. No correlation using the Pearson coefficient could be found for age and volume.ConclusionOur study demonstrated that the BMI is a predictive indicator that can be used in the preoperative planning of reconstructions using free flaps. Depending on the defect location, the BMI can be considered to predict the thickness of the free flap and may influence the surgeon’s choice.On the other hand, a lower correlation between BMI and flap thickness encourages the use of standard flaps if more volume is desired, as the DIEP flap might be sufficient even in normal-weight women. Flaps of distal body parts, such as the forearm or lower leg, are not prone to such predictions and require other selection criteria.

Abstract P2-15-06: Light-based bioprinting of vascularized fatty tissue for the development of biological breast implants

Abstract Although multi-modal and ablative treatment strategies for breast cancer are becoming more popular, partial or full mastectomy is still a most common intervention. While proving to be effective in curing the cancer, it leaves the patient disfigured, which can pose a considerable psychological burden. Hence, reconstructive breast surgery is continuing to increase in importance as it offers the possibility to at least partially restore the original look of the breast. Autologous adipose tissue transfer techniques, amongst them the surgical gold standard flap surgery and liposuction-based fat grafting, present natural solutions with the patient’s own tissue, but either produce a considerable secondary wound or are insufficient to address larger defects. Synthetic solutions like silicone implants on the other hand can also be used to fill large defects and only require minimal surgical intervention, but suffer from foreign body-associated complications like fibrosis. Tissue engineering biological breast implants of arbitrary size with no or minor insult to the patient’s body and excellent biocompatibility, exclusively using biomaterials and patient-specific adipose cells, could open a new chapter for breast reconstruction. Such an approach has become an intriguing possibility through the rise of powerful biofabrication technologies in the last two decades, namely three-dimensional bioprinting. Bioprinting marries additive manufacturing with biomaterials and living cells with the aim to create life-mimicking tissues and organs, and while it is mainly focused on research today, current endeavors push for application in regenerative medicine. In our work we sought to fabricate adipose tissue constructs using light-based bioprinting to investigate the potential application of such technology for future reconstructive breast surgery. The engineered tissue blocks were designed to mimic native human adipose tissue by comprising fat, connective tissue and endothelial cells. Being specifically placed by the bioprinter within extracellular matrix-like hydrogels, the cells were cultured in vitro and differentiated within the cultivation time of up to 4 weeks to form an adipose-like tissue. Live imaging showed high viability of bioprinted tissue blocks over the whole cultivation period and pronounced cellular reorganization. Confocal and histological analyses revealed a dynamic tissue maturation process with increasing proportions of differentiated adipocytes, ECM remodeling and formation of microvascular structures. In conclusion, the obtained results gave proof to the concept of engineering adipose tissue through bioprinting and could lay the groundwork for the development of all-natural biological breast implants. Citation Format: Nina Hedemann, Alexander Thomas, Nils Tribian, Lutz Kloke, Dirk Bauerschlag, Marion van Mackelenbergh. Light-based bioprinting of vascularized fatty tissue for the development of biological breast implants [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-15-06.

Continuous intraoperative perfusion monitoring of free microvascular anastomosed fasciocutaneous flaps using remote photoplethysmography

Flap loss through limited perfusion remains a major complication in reconstructive surgery. Continuous monitoring of perfusion will facilitate early detection of insufficient perfusion. Remote or imaging photoplethysmography (rPPG/iPPG) as a non-contact, non-ionizing, and non-invasive monitoring technique provides objective and reproducible information on physiological parameters. The aim of this study is to establish rPPG for intra- and postoperative monitoring of flap perfusion in patients undergoing reconstruction with free fasciocutaneous flaps (FFCF). We developed a monitoring algorithm for flap perfusion, which was evaluated in 15 patients. For 14 patients, ischemia of the FFCF in the forearm and successful reperfusion of the implanted FFCF was quantified based on the local signal. One FFCF showed no perfusion after reperfusion and devitalized in the course. Intraoperative monitoring of perfusion with rPPG provides objective and reproducible results. Therefore, rPPG is a promising technology for standard flap perfusion monitoring on low costs without the need for additional monitoring devices.

QS21. Surgical Outcomes of Autologous Breast Reconstruction in Low BMI Patients; Beyond the Gold Standard DIEP Flap

QS21. Surgical Outcomes of Autologous Breast Reconstruction in Low BMI Patients; Beyond the Gold Standard DIEP Flap

A Modification of the Standard Grisotti Flap

A Modification of the Standard Grisotti Flap

The extended latissimus dorsi flap in oncology breast reconstruction: Case report and literature review

Abstract The latissimus dorsi myocutaneous flap was one of the first methods of oncology breast reconstruction described. However, the standard latissimus dorsi flap alone often does not provide sufficient volume for breast reconstruction, it may have not been the first choice anymore. The design of an extended latissimus dorsi flap has involved including the parascapular and scapula fat fascia in addition to the lumbar fat for additional volume. The main advantage of the extended latissimus dorsi flap is that it can provide autogenous tissue to restore breast volume, it is suitable for Asian women whose breasts are not too large. The author reported the first case of breast reconstruction after mastectomy using the extended latissimus dorsi flap at Viet Duc University Hospital with a 5-year follow up and literature review. Keywords: Extended latissimus flap, breast reconstruction, breast cancer.

Enhancing Microsurgical Assistant Experience with Bifocal Safety Glasses: A Low-Cost Alternative to Surgical Loupes.

The standard flap harvest is performed under loupe dissection. It is not infrequently that a medical student or physician assistant participates in the role of first or second assist. Such scenarios have impressed upon us the observation that these surgical assistants seldom use loupes or any other form of visual magnification. The reasons for this are likely multifaceted and may be related to cost as well as perceived opinions of colleagues. The benefit of encouraging optical aid use among surgical assistants encompasses an augmented surgical and learning experience. The aforementioned barriers, however, prohibit the use of loupes. We have found bifocal safety glasses to be an adequate alternative (Fig. 1). As compared to Galilean or prismatic loupes, which utilize multiple lenses and can magnify up to eight times without distortion (in the case of prismatic loupes), single-lens magnifiers can magnify up to 1.5 times without distortion or significant loss of working distance. Although this level of magnification is not acceptable for the primary surgeon, the added benefit of single-lens magnification is certainly superior to total lack of magnification typically utilized by nonresident surgical assistants.Fig. 1.: Standard bifocal safety glasses with +1.00 diopter strength.Bifocal safety glasses need to be selected in order to allow for maximal magnification at the optimal working distance. With this in mind, we recommend lower-powered magnifiers (i.e., diopters between +0.75 and +1.50 diopters), as these allow for crisp magnification and accommodation without causing eye fatigue. It is important to note the conversion of diopter to magnification is described by the equation m = d/4 + 1, therefore a +1.00 diopter would result in m = ¼ + 1 = 1.25× magnification. As compared to surgical loupes, bifocal safety glasses have the added benefit of being lightweight. The detrimental effect of loupes on cervical spine health has been well documented in surgeons of all levels and across multiple specialties; surgeons with severe cervical spine pain can use bifocal safety glasses as an alternative to loupes in cases where high-power magnification is not needed.1,2 In addition, single-lens magnifiers are not cost-prohibitive. They can be purchased for less than $15, which is markedly less than the typical price of loupes.3 The design of bifocals is discreet, as they resemble safety glasses typically worn in the operating room, and this mitigates any worry about eliciting negative opinions from colleagues. Bifocal safety glasses are a cost-conscious, comfortable, and inconspicuous optical aid that should be utilized by microsurgical assistants when loupes are not available. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Динамика изменений микропериметрических параметров сетчатки при различных методиках закрытия макулярных разрывов на основе аутопластики внутренней пограничной мембраны

Currently, vitreoretinal surgery is one of the most effective methods of treating macular holes that can improve the quality of vision, and the most common method of such treatment is vitrectomy with the removal of the internal border membrane around the rupture and the use of autoplasty of the internal border membrane. Microperimetric retinal testing measures the sensitivity of the retina at certain points on a larger surface and detects relative or absolute microscotomas, which allows you to objectively assess the state of the central part of the retina. At the same time, the search for ways to reduce the risk of macular surgery complications and improve functional results continues. Purpose. To propose a new technique for macular tear surgery, which is based on autoplasty of the VPM and reduction of microtraumatization of the retinal layers. Material and methods. The results of surgical treatment of 240 patients (240 eyes) with a diagnosis of macular holes were analyzed. All patients underwent surgical treatment for MH. Depending on the method of closing the macular hole, the patients were divided into two groups: group 1 – patients who underwent surgical treatment using the standard introverted flap technique. Group 2 – patients who were operated on according to the original method with partial peeling of ILM in the macular area. All parameters in the preoperative period were statistically comparable. Results. The most significant are the results obtained on the 30th day after surgical treatment. According to the results of surgical treatment, there was a significant excess of light sensitivity parameters in the nasal part of the pattern used: the upper-nasal and lower-nasal quadrants, where peeling was not performed. Conclusion. During this technique, there is a preservation ILM, which reduces the risk of intraoperative damage to the retinal layers. A higher functional result was obtained. Key words: microperimetry, macular rupture, ILM peeling.

Effectiveness of Different Surgical Flap Delay Methods and Their Systemic Toxicities.

The surgical flap delaying has been shown to be effective in preventing partial flap loss or in preparing larger flaps. However, there is no gold standard flap delay method in the literature. In this study, the authors aimed to compare 3 types of surgical delay methods to determine which model would increase more flap survival. The authors also investigated the effect of delay methods on circulating mononuclear leukocytes as a parameter of DNA damage. Twenty-four Sprague-Dawley male rats were divided into 4 groups. All subjects had a 10 × 3 cm modified McFarlane flap. Surface area measurements, biopsies, and blood samples were taken on the day of sacrification; 7th day for the control group and 14th day for delay groups. Between incisional surgery delay groups, a significant difference was found in necrosis and apoptosis in the bipedicled group, and only necrosis in the tripedicled group compared to the control. In terms of DNA damage, it was found higher in all experimental groups than in the control group. Both incisional surgical delay procedures' results were meaningfully effective when only incisions were made without the elevation of flaps. In conclusion, bipedicled incisional surgical delay seems to be the most effective method in McFarlane experimental flap model whereas two-staged surgeries may increase the risk of systemic toxicity.

The Path to ‘Dieps by Dinner’ Involves The Entire Operative Team

More and more breast cancer patients are turning to autologous options for reconstruction. Deep Inferior Epigastric Perforator (DIEP) flap reconstruction is considered the gold standard flap breast reconstruction procedure; however, it requires a significant number of resources, including two surgeons and microsurgical equipment. A multidisciplinary group was tasked with reducing operative time of DIEP flap procedures by 25% so that complex surgeries can become more routine and accessible to patients. Using participatory ergonomics, members of the operative team were engaged to identify interventions. Following implementation, 22 DIEP flap cases were evaluated using workload surveys and patient outcomes to determine the success of the interventions. DIEP flap surgical durations were reduced by 25% on average (M=12.9 hours, SD=5.7 to M=9.7 hours, SD=1.4). When cases lasted longer than 9 hours, surgeons reported 31% more physical demand and 78% more fatigue than cases that were 9 hours or less. Survey results linked positive team characteristics to reduced frustrations and distractions.

Coverage of Severely Burn Injured Knee with Supercharged Reverse ALT Flap: Avoiding Limb Amputation

Primary skin and soft tissue reconstruction of large defects around the knee may be a challenge for the plastic surgeon. Fasciocutaneous flaps play an essential role in achieving functional and aesthetic restoration. We present the surgical reconstruction of an extensive 3rd degree burn injury with knee joint capsule and ligaments involvement in a 51-year-old patient. Devitalized structures were firstly debrided and a supercharged reverse anterolateral thigh (RALT) flap was used to cover the resultant tissue defect. The ALT fascia was employed to reconstruct the damaged joint capsule in order to restore articular function. The supercharged RALT flap has a greater blood supply compared with standard flaps and enables us to use larger flaps to reconstruct extensive knee and proximal leg tissue defects.

Использование фемтосекундрого лазера VisuMax для проведения кросслинкинга роговичного коллагена

Introduction. Corneal collagen crosslinking is a treatment method of advanced keratoconus, improving a «compaction» thickness or increasing a strength of corneal stroma. The high functional results and the shortened postoperative periods in patients during crosslinking using a femtosecond laser determine the prospects for a further study of this trend. Purpose. To study the conditions and to apply the femtocrosslinking method based on the standard flap formation options using the VisuMax femtolaser device. Material and methods . There were 20 patients under our observation with progressive keratoconus (20 eyes) who underwent femto cross-linking of corneal collagen using a VisuMax femto-laser. All patients were examined using the standard preoperative ophthalmologic methods (visometry, tonometry, keratorefractometry, pachymetry, keratotopography). The fact of progression of keratoconus was established on the basis of dynamic fellow-up for at least 6 months. Results. Features of the method of femto-cross-linking of corneal collagen using the VisuMax are: 1) extension of the flap leg in the operating settings (the angular size of the bridge increased to 320°); 2) formation of the circular corneal pocket parallel to the front surface via the femto-laser and one arcuate corneal incision depth of 140–160 µm, and the diameter of the pocket and the arcuate cut – 7.9–8.7 mm.All patients (20 eyes, 100%) were achieved the stabilization of ecstatic process within the follow-up period of 6 and 12 months. Conclusion. The conditions for the use of a laser installation VisuMax (Carl Zeiss) using the «FLAP» program in the operation of corneal collagen femtocroslinking have been determined. The advantage of this method is to simplify the classical way of doing cross-linking and increase its effectiveness. Promising is the further study of technology, dynamic control over patients and long-term results.

Optimization of the homodigital antegrade island flap for fingertip reconstruction: New dissection sequence based on cadaver study findings

IntroductionThe homodigital antegrade island flap pedicled on the proper palmar digital artery is very useful for covering fingertip defects. However, it has its drawbacks, such as the risk of stiffness due to retractile scars and the need for extensive dissection with long-lasting dysesthesia in some cases. In clinical studies, expanding the skin paddle with V-shaped incisions increases the flap's advancement. We wanted to know whether making these V incisions for paddle expansion would make dissection on the volar side of the proximal interphalangeal joint unnecessary. MethodsA cadaver study was performed with four fresh-frozen upper limbs. Sequential dissection was carried out on 32 flaps, allowing us to compare the advancement obtained and the area of the flap's paddle between each step. ResultsCrossing the palmar crease of the proximal interphalangeal joint provides only 2mm advancement of the homodigital antegrade flap. Adding one or two V-shaped incisions in the flap with limited dissection provides additional advancement of 4.1mm (p<0.05) and 6.9mm (p<0.05) relative to the standard flap. DiscussionOur study shows the possibility of increasing the homodigital antegrade flap's advancement – without having to extend the dissection proximally to the PIP joint – by making V-shaped incisions in the paddle. Based on our findings, we have proposed a new flap dissection sequence.

A retrospective study of fibula flap over a ten-year period

Background: Nowadays, fibula flap is the standard flap for jaw reconstruction. Its benefits are it can be osteomized and contoured to fit the defects over maxilla or mandible, and even both. Due to the nature of this bone being dense, it has cortical bone stress-bearing potential for implant surgery, either simultaneously or after the wound has healed. However, the skin to bone relationship offers limited freedom, so most of the time skin paddle position to the bone position will be compromised. So, larger composite defects on the maxillofacial region frequently need to be combined with other soft tissue flaps. In addition, donor site morbidity occurs sometimes.

Periodontal regeneration with autologous periodontal ligament-derived cell sheets - A safety and efficacy study in ten patients.

BackgroundPeriodontitis results in the destruction of tooth-supporting periodontal tissues and does not have the ability to heal spontaneously. Various approaches have been introduced to regenerate periodontal tissues; however, these approaches have limited efficacy for treating severe defects. Cytotherapies combine stem cell biology and tissue engineering to form a promising approach for overcoming these limitations. In this study, we isolated periodontal ligament (PDL)-derived cells from patients and created cell sheets with “Cell Sheet Engineering Technology”, using temperature responsive culture dishes, in which all the cultured cells can be harvested as an intact transplantable cell sheet by reducing the temperature of the culture dish. Subsequently, the safety and efficacy of autologous PDL-derived cell sheets were evaluated in a clinical setting.MethodsA single-arm and single-institute clinical study was performed to verify the safety and efficacy of autologous PDL-derived cell sheets in patients with periodontitis. Wisdom teeth were extracted from patients diagnosed with chronic periodontitis, ranging in age from 33 to 63 years (mean [±SD], 46 ± 12), and periodontal tissues were scraped for cell sources. Three-layered PDL-derived cell sheets were constructed using temperature-responsive culture dishes and transplanted in an autologous fashion following standard flap surgeries. Bony defects were filled with beta-tricalcium phosphate granules. Clinical variables were evaluated at baseline, 3 months, and 6 months. Cone-beam computed tomography was performed at baseline and 6 months. Additionally, mid-long-term follow-up has been performed with patients’ agreements.ResultsOur method was found to be safe and no severe adverse events were identified. All the findings, including reduction of periodontal probing depth (mean ± SD, 3.2 ± 1.9 mm), clinical attachment gain (2.5 ± 2.6 mm), and increase of radiographic bone height (2.3 ± 1.8 mm), were improved in all 10 cases at 6 months after the transplantation. These therapeutic effects were sustained during a mean follow-up period of 55 ± 19 months, and there were no serious adverse events.ConclusionsThe results of this study validate the safety and efficacy of autologous PDL-derived cell sheets in severe periodontal defects, and the stability of this efficacy during mid-long-term follow up. This cytotherapeutic approach, based on cell sheet engineering, offers an innovative strategy to treat the recognized unmet need of treating severe periodontal defects.

Intraoperative Mapping of the Subfascial Plexus Using the Transillumination Method for Head and Neck Reconstruction with Free Style Anterolateral Thigh Flaps.

Without well recognizing the vascular territories of the perforator, surgery might damage the pedicle and diminish flap survival. This study described a transillumination method for intraoperative mapping of the subfascial plexus of the perforator in the head and neck reconstruction with an anterolateral thigh (ALT) flap and also compared the perioperative outcomes and complications of the method with those of the conventional two-pedicle ALT flap. Between January 2011 and December 2017, 26 patients who underwent head and neck reconstruction with ALT flaps were evaluated as follows: 13 underwent the transillumination method (case group), and 13 (age- and sex-matched) underwent standard two-pedicle flap procedures (control group). Demographic factors, diagnosis, flap size, recipient site, perioperative data, and postoperative complications were compared between the two groups. There was no significant difference in age, sex, diagnosis, recipient sites, and flap size between the case and control groups. Regarding the perioperative outcomes, the harvesting time was significantly shorter in the case group than in the control group (60 vs. 100 minutes, p < 0.001). The operative time was shorter in the case group than in the control group, but this difference was not statistically significant (300 vs. 420 minutes, p = 0.058). The transillumination method can allow plastic surgeons to easily identify the perforator vascular plexus of the ALT flap, which facilitates intraoperative flap design in head and neck reconstruction.

Clinical evaluation of the effect of standard and modified standard flaps design in the removal of mesio-angular impacted lower 3rd molar

Aim of the study: The propose of this study was designed to establish a successful comparison between removal of impacted lower third molar (wisdom tooth) using two different flap designs (standard and modified standard flap) in post-operative pain, trismus and swelling, Methodology: The comparison was done after the removal of the impacted teeth using a specific criteria that was numbered and described in a this research, a total of ten systemically free patient with mesio-angular impacted lower third molar was choose as a candidate for conducting this research, the patients was divided into two groups (group 1 and group 2), a standard flap was used with the first group, in standard flap the vertical releasing incision was started at the level of buccal groove of the seven, while in group 2 a modified standard flap was used, in modified standard flap the vertical releasing incision was started just distally to the first molar .Conclusion: finally, we concluded at the end of this study that the choice between these two flaps in removal of impacted lower third molar have no significant difference when compared to post-operative pain, swelling and trismus.