Surgical Flaps Research Articles

The Vascular Anatomical Basis for a Well-Designed Reconstruction of the Ala Nasi by a Microsurgical Preauricular Flap Technique

Background: A microsurgical auricular flap represents a single-step technique for the reconstruction of full-thickness defects of the ala nasi. To achieve the best surgical outcomes, it is essential to have an exhaustive knowledge of the vascular network to improve the management of the surgical flap. This study aimed to provide an anatomical and surgical guide for a well-designed reconstruction of the ala nasi using a free preauricular flap. Methods: In this study, three fresh-frozen and two formalin-fixed human head specimens injected with red silicone rubber to enhance the arterial facial system were used. The reconstruction of the full-thickness defect of the ala nasi was performed using a microsurgical auricular flap technique, with the dimensions of the ala nasi and the preauricular flap duly noted. In addition, anatomical dissections were conducted, during which the positions and diameters of the main donor and recipient vessels were measured. Results: A presurgical evaluation was performed to define the flap design. A comparison of the shape and mean dimensions of the ala nasi defect (height 9.66 ± 1.40 mm; thickness 3.52 ± 0.53 mm) and the preauricular flap (height 8.50 ± 2.68 mm; thickness 3.92 ± 1.29 mm) indicated that this flap was an optimal option for the reconstruction of the ala nasi. The surgical procedure involved the full-thickness removal of the ala nasi, and the harvesting and insertion of the preauricular flap. The anatomical measurements demonstrated that the facial artery and veins were the optimal recipient vessels, with a diameter of >1 mm (2.08 ± 0.56 and 2.85 ± 0.74 mm), suitable for anastomosis with the superficial temporal artery and vein (1.86 ± 0.58 and 1.66 ± 0.15 mm). In addition, the postsurgical evaluations indicated a slight mean difference in the thickness (1.14 ± 0.65 mm) and height (1.68 ± 1.18 mm) between the ala nasi and helix and a satisfactory VAS score (7.9 ± 0.57). Conclusions: Our surgical and anatomical data provide compelling evidence in favour of free preauricular flap reconstructions of the ala nasi. This procedure allows for the correct choice of recipient vessels and the creation of a well-designed surgical flap.

Effect of ultrahigh frequency ozone therapy on oxidative metabolism in the blood of rats with ischemic skin flaps: A preclinical experimental randomized study

Background. Maintaining and restoring skin microcirculation in surgical flaps, as well as accelerating rehabilitation after skin flap transplantation, in order to mitigate the consequences of burns and injuries, remain a pressing issue. In addition to various timings and techniques for plastic surgery, physiotherapeutic approaches prove to be efficient and include low-intensity electromagnetic radiation in millimeter waves as their prominent techniques. In recent years, experts have paid an increasing attention to the application of low-intensity electromagnetic radiation across different frequency ranges for the enhancement of microcirculation in patients after surgical correction of burn consequences. However, this approach is yet to be further validated. Objective. To investigate the effect of different combinations of ultrahigh frequency electromagnetic radiation with ozone therapy on the oxidative metabolism of blood in rats using a model of ischemic skin flaps. Methods. A preclinical experimental randomized study was conducted on 100 adult male Wistar rats weighing between 200 and 250 grams. Five equal-sized groups of animals were formed in the study: Group 1: intact (no interventions), and Groups 2, 3, 4, and 5: after surgical intervention (modeling of ischemic skin flaps). Animals in Group 2 (control group) received no therapeutic procedures. Rats in Groups 3 and 5 underwent a 10-minute course of electromagnetic radiation exposure with a dose of 0.06 mJ for seven days. Animals in Group 3 were exposed to electromagnetic radiation of ultrahigh frequency with a range of 53–78 GHz. Animals in Group 4 received injections of ozonized saline solution (with a saturating ozone concentration in the ozonized oxygen mixture of 3000 µg/L) daily for 7 days, administered intraperitoneally at a volume of 1 mL. Group 5 underwent a combined treatment: daily exposure to ultrahigh frequency electromagnetic radiation along with intraperitoneal ozone therapy (the application modalities of these treatments were similar to those used in Groups 3 and 4, respectively). The intensity of lipid peroxidation, peroxide resistance in erythrocytes, and overall antioxidant system activity were assessed in order to investigate the balance of pro- and antioxidant systems in plasma and erythrocytes. Additionally, the study involved determination of the level of malondialdehyde content and evaluation of the activity of superoxide dismutase and catalase in erythrocytes. The obtained date were analyzed, using MS Office 2013 (Microsoft Corporation, USA) and Statistica 10 (StatSoft, USA). Results. The conducted analysis revealed an antioxidant effect from ultrahigh frequency electromagnetic radiation, with this effect being enhanced by ozone therapy. In addition, the study detected the inhibition of free radical oxidation under the ultrahigh frequency electromagnetic radiation and ozone therapy. Conclusion. Thus, the positive effects of the studied therapeutic factors manifest at the systemic level, as evidenced by the optimization of biochemical parameters and indicators of oxidative metabolism in the plasma of animal blood. It has been established that ultrahigh frequency electromagnetic radiation, administered in a noise mode, exerts a regulatory effect on pro- and antioxidant systems in the body, as demonstrated in a model of transplanted skin flap. This intervention leads to a reduction in the severity of oxidative stress and an enhancement of antioxidant reserves in the blood. The observed effect is further amplified with the additional application of ozone therapy.

Manual Hair Removal for Intraoral Flaps: a Simple Practice for Professional Education and Patient Cancer Care.

After resection of malignant tumors of the head and neck, reconstructions are commonly performed using surgical free flaps. In non-irradiated patients, hair may continue to grow at the reconstruction site after surgery, causing undesirable effects such as difficult to maintain oral hygiene, food and saliva accumulation, halitosis, dysphagia, moral distress, and impact on intimacy and sexuality. Until a standardized laser therapy protocol is available, manual depilation isan option that should not be underestimated to improve the patient's quality of life and available to every oral healthcare team. This case illustrates a simple practice that contributes to improving patients' quality of life and oral health in an interprofessional way.

Application of Modified Skin Stretching for Soft Tissue Defect Reconstruction in the Ankle and Foot: A Retrospective Report.

The failure rate of foot and ankle soft tissue defect reconstruction with flap is relatively high, often posing a significant burden on patients. The aim of this study is to explore the effectiveness of repeated stretch sutures in repairing skin and soft tissue defects of the ankle and foot. Twenty-three patients with ankle and foot skin and soft tissue defects were retrospectively analyzed between February 2016 and February 2019. Sutures were repeatedly stretched every 3-5 days. Local skin grafting was performed if necessary after wound surfaces disappeared or exposed tendons and bones were covered by soft tissue. Wound healing time, postoperative healing area, Vancouver Scar Assessment Scale, sensation, and function of the new skin were evaluated. Healing time was 17-35 (24.43 ± 5.29) days. Ten patients wholly healed, and 13 healed by approximately 70.08% ± 6.59%. The Vancouver Scar Assessment Scale average score was 2.83 ± 1.19 points, of which 15 cases were excellent (0-3 points) and 8 cases were good (4-7 points). The sensation and function of the new skin after repair were equivalent to those of normal skin after the last follow-up. Applying repeated tension sutures on the skin and soft defects of the ankle and foot reduced the skin graft area and decreased complex high-risk surgical flaps' use and transplantation area.

Meta analysis of 2059 patients assessing early discharge after DIEP flap breast reconstruction: Comprehensive outcomes before post-operative day 5

Autologous reconstruction with DIEP flap has illustrated greater patient satisfaction with both aesthetic satisfaction and reconstructive treatment process when compared to implant-based reconstruction longitudinally. However, DIEP flap breast reconstruction is associated with longer in-patient hospitalizations to monitor flap status. This systematic review and meta-analysis aims to report outcomes regarding the use of enhanced recovery after surgery (ERAS) protocols, particularly looking at the impact on complication rates in patients who undergo DIEP flap procedures and are discharged within 5 days after surgery. A computerized search was conducted on September 29th, 2023 using the MeSH terms "Free Tissue Flaps" OR "Myocutaneous Flap" OR "Surgical Flaps" AND "Patient Discharge". Twenty-four papers reporting on 2059 patients were included in the study, and four study groups were created by length of stay as follows: LOS 1-1.99 days = Group 1, LOS 2-2.99 days = Group 2, LOS 3-3.99 = Group 3, and LOS 4-5 days = Group 4 (control). An independent samples t-test was performed to compare the mean rates of each complication between Groups 1 and 4, Groups 2 and 4, and Groups 3 and 4. This meta-analysis showed no significant differences between rates of hematoma, seroma, infection and reoperation between groups. There was a significantly lower rate of total flap loss in all 3 groups with LOS less than 4 days when compared to the group with LOS between 4 and 5 days. This meta-analysis shows that appropriate patients may be discharged safely as early as POD1 following DIEP flap.

Peri anal region is an overlooked location for pilonidal recurrence after surgical excision and closure – A case series

Introduction and importancePatients with pilonidal disease (PD) often undergo wide excision of pilonidal sinuses and flap-based closures. Patients who failed these procedures can have recurrent perianal wounds obscured by hair and unrecognized even by the treating physicians. In this report, we describe a series of pilonidal patients with recurrent disease and perianal wounds. Case presentationFive pilonidal patients with recurrent disease after surgical excision and flap closure were referred to our Pilonidal Care Clinic. All five were found to have perianal wounds. Each patient was treated with regular manual and laser epilation and only one patient required a Gips procedure. All wounds were successfully healed. Clinical discussionAfter removal of hair at the perianal region, patients with recurrent pilonidal disease can expose a pilonidal sinus that was previously unrecognized. Peri-anal wounds can have poor wound healing due to the close proximity of the wound to the anal verge, risk of contamination, difficulty of consistent observation of the wound, and moist environment of the anus that retains bacteria. Careful consideration of proper wound care post-excision of perianal pilonidal sinuses should be prioritized. ConclusionsPilonidal perianal wounds after previous surgical excision and flap closure can be obscured by hair, resulting in recurrent pain and drainage. The perianal wounds can be successfully healed with regular manual and laser epilation and selectively excised using Gips procedure.

Medication-related osteonecrosis of the jaw: a retrospective single center study of recurrence-related factors after surgical treatment

ObjectivesTo provide an overview of the features of patients with medication-related osteonecrosis of the jaw (MRONJ) and explore recurrence-related factors after surgery.Materials and methodsAll pathological records of patients diagnosed with osteonecrosis or osteomyelitis of the jaw were reviewed. Only patients who had a history of use of medication related to bone turnover were included. All demographic and clinical characteristics were collected during review. Univariate and logistic regression analyses were performed to evaluate the associations between risk factors and recurrence. A p value < 0.05 was considered to indicate statistical significance in all analyses.ResultsA total of 313 patients were ultimately included. Most patients (89.14%) underwent bone turnover-related treatment due to malignancy. The breast and prostate were the most common locations of primary tumors in females and males, respectively. Almost all MRONJ patients experienced inflammatory symptoms. Recurrence occurred in 55 patients at 60 locations. The total recurrence rate was 16.85%, with no significant differences between the maxilla and mandible. Extensive surgery and flap transfer were strongly related to a lower recurrence risk. Nearly 80% of patients had recurrence-related symptoms within 6 months.ConclusionWhen MRONJ is treated with surgical methods, extensive resection and flap transfer can reduce recurrence risk. Six-month follow-up is needed to exclude recurrence after surgery.Clinical relevanceThis study revealed the surgical-related risk factors, such as extensive surgery and flap transfer, when treating MRONJ patients, and 6-month follow-up is needed to detect recurrence. This could provide clinical guidance for head and neck surgeons.

Challenging Dogmas in Plastic Surgery.

In medicine, dogmas are subject to evolution and refinement as new research and technologies emerge. The aim of this study was to search for dogmas which were challenged and potentially revised in the plastic surgery field. A search on PubMed for "dogma and plastic surgery" yielded 80 papers. The queries "surgical dogma and craniofacial surgery" and "surgical dogma and flap" returned 9 and 21 papers, respectively. "Surgical dogma and hand" and "surgical dogma and wound healing" produced 41 and 25 papers, respectively. Removing 35 duplicate papers, 141 abstracts were reviewed. Of these, 78 were excluded, leaving 63 papers for analysis. The dogmas being challenged within the field of plastic surgery were classified into various categories. The distribution of these challenged dogmas was as follows: wound healing: 14.29%, epinephrine use: 9.52%, flap surgery: 7.94%, breast reconstruction: 6.35%, rhinoplasty: 7.94%, hand surgery: 4.76%, pressure sores: 4.76%, chemical peel: 4.76%, and hand injuries: 3.17%. The widespread focus on improving wound healing techniques indicates a need for more effective treatments and faster recovery times. Significant attention has been directed toward the use of epinephrine, particularly in fingers, which may reflect ongoing debates about its safety. Innovations and improvements in flap surgery could lead to better reconstructive outcomes. Challenging existing dogma is a vital process and a driving force in the advancement of clinical science. These challenges and potential revisions reflect the dynamic nature of plastic surgery, where ongoing research, patient outcomes, and evolving societal norms drive continuous improvement and adaptation in practices and principles.

Escalating Surgical Treatment for Left Ventricular Assist Device Infection and Expected Mortality: Clinical Risk Prediction Score.

Left ventricular assist devices (LVAD) improve survival for patients with cardiac failure, but LVAD-specific infection (VSI) remains a challenge with poorly understood predictive risk factors. The indications and use of escalating medical treatment to surgical debridement and potential flap reconstruction are not well characterized. A retrospective review of consecutive patients undergoing primary LVAD implantation at a tertiary academic center was performed. The primary outcome measures were 90-day and overall mortality after VSI. Cox proportional hazards regression was used to generate a risk prediction score for mortality. Of the 760 patients undergoing primary LVAD implantation, 255 (34%) developed VSI; of these patients, 91 (36%) were managed medically, 134 (52%) with surgical debridement, and 30 (12%) with surgical debridement and flap reconstruction. One-year survival after infection was 85% with median survival of 2.40 years. Factors independently associated with increased mortality were diabetes (hazard ratio [HR] 1.44, p = 0.04), MRSA infection (HR 1.64, p = 0.03), deep space (pump pocket or outflow cannula) involvement (HR 2.26, p < 0.001), and extracorporeal membrane oxygenation after LVAD (HR 2.52, p < 0.01). Factors independently associated with decreased mortality were flap reconstruction (HR 0.49, p = 0.02) and methicillin-sensitive Staphylococcus aureus infection (HR 0.63, p = 0.03). A clinical risk prediction score was developed using these factors and showed significant differences in median survival, which was 5.67 years for low-risk (score 0 to 1), 3.62 years for intermediate-risk (score 2), and 1.48 years for high-risk (score ≥3; p < 0.001) patients. We developed a clinical risk prediction score to stratify patients with VSI. In selected cases, escalating surgical treatment was associated with increased survival. Future work is needed to determine whether early surgical debridement and flap reconstruction can alter outcomes in select cases of VSI.

The value of perforator flap reconstruction in painful soft tissue calcifications

Soft tissue calcifications frequently cause debilitating pain and functional impairments, considerably affecting patients’ quality of life. As they are rare entities, evidence remains sparse, especially regarding treatment effectiveness and recurrence rates. While both pharmacological and surgical treatments may alleviate symptoms, complete resection is currently believed to prevent long-term recurrence of deposits. To improve understanding and raise awareness for soft tissue calcifications, the goal of this study was to review the current state of treatment and to compare benefits and possibilities of flap reconstruction versus simple excision in improving quality of life. Furthermore, we include a successful case report of complete resolution of symptoms following quadruple perforator flap reconstruction. By systematic literature review, studies published in MEDLINE between 1980 and 2024 reporting on surgical treatment and outcome of soft tissue calcifications were included, in addition to a detailed description of our case report. A total of 53 studies reporting on 197 patients with soft tissue calcifications were included. Simple surgical excision was the most commonly (85.9%) employed procedure, demonstrating a substantial recurrence rate of 13.3%. In contrast, no patients who underwent radical excision experienced recurrence. Dermal matrix grafts and flap reconstruction were successfully used in patients requiring substantial tissue coverage, highlighting their value in complex defect reconstruction following radical excision. The combination of complete surgical resection and flap reconstruction reduces recurrence rates and improves postoperative outcomes and quality of life of these patients, supporting early radical surgical intervention as the gold standard treatment for soft tissue calcifications.

The use of incisional negative pressure wound therapy on high-risk breast cancer mastectomy patients

BackgroundThe main complications seen in patients who have undergone modified radical mastectomy (MRM) are seroma, surgical site infection, hematoma, wound dehiscence, flap necrosis, and nerve damage. While these complications lead to some problems the most feared effect in the early period is that they cause a delay in adjuvant treatment. Incisional Negative Pressure Wound Therapy (iNPWT) decreases wound dehiscence by reducing oedema and tension, especially in the incision line. This study aim to compare recovery times and wound site complications between patients treated with conventional wound dressings and patients treated with iNPWT after MRM. MethodsA retrospective screening was made of the data of 50 patients who underwent MRM because of breast cancer in the General Surgery Clinic of XXX Hospital between 2018 and 2022, and were at high-risk of wound site complications. Two groups were formed as 30 patients applied with iNPWT and 20 patients applied with conventional dressings. ResultsThe mean age of the 50 female patients was 53.58 years (range, 30–80 years). The most frequently seen complications were seroma (20 patients) and partial flap ischaemia (14 patients). The mean number of iNPWT applications was 1.30 (range, 1–2), and the mean number of days of application was 4.47 (range, 2–9). Postoperative seroma was observed in 8 patients in the iNPWT group and in 12 patients in the conventional dressings group (p = 0.018). Flap ischaemia and the probability of dehiscence was determined at a statistically significantly higher rate in the patients in the conventional dressings groups (p = 0.005, p = 0.021). ConclusionThe results of this study demonstrated that the use of iNPWT significantly reduced the amount of postoperative drainage, thereby contributing to early drain removal. Furthermore, iNPWT significantly reduced postoperative seroma, flap ischaemia, and flap dehiscence compared to conventional dressings.

Increased Patient Age as a Risk Factor Following Free Flap Reconstruction after Breast Cancer: A Single Institutional Review of 2,598 Cases.

Autologous breast reconstruction (ABR) after mastectomy is increasing due to benefits over implant-based reconstruction. However, free flap reconstruction is not universally offered to patients of advanced age due to perceived increased perioperative risk. Patients undergoing free flap breast reconstruction at our institution from 2005 to 2018 were included. Risk-adjusted logistic regression models were fit while controlling for demographic and comorbid characteristics to determine the association of age with the probability of venous thromboembolism (VTE), delayed healing, skin necrosis, surgical site infection (SSI), seroma, hematoma, hernia, and flap loss. Linear predictions from risk-adjusted logistic regression models were used to create spline curves and determine the risk of outcomes associated with age. A cohort of 2,598 patients underwent free flap breast reconstruction in the period examined. The median age was 51 with approximately 9% of patients being 65 or older. Increased age was associated with a greater risk of delayed healing, skin necrosis, and hematoma after surgery. There was no increased risk of medical complications such as VTE or complications such as flap loss, seroma, or SSI. A set age cutoff for patients undergoing free flap breast reconstruction does not appear warranted. There is no difference in major surgical complications such as flap loss with increasing age. However, older age does predispose patients to specific wound complications such as hematoma, skin necrosis, and delayed wound healing, which should guide preoperative counseling. Further, medical complications do not increase with advanced age. Overall, however, the safety of ABR in older patients appears uncompromised.

A Comprehensive Flap Classification: Beyond the Reconstructive Ladder.

Perforator flaps have progressed massively in the last years. The improved vascular imaging techniques and the use of supermicrosurgery have shifted the practice from the traditional predefined angiosomal flaps to the endless variations of custom-made flaps. In this article, we propose a broadened classification of free-style flaps in 3 categories, the angiosomal, including all traditional perforator flaps and their variations, the extra-angiosomal, including flaps that are manufactured to include tissue from a different angiosome, such as turbocharging or supercharging a flap, and neoangiosomal flaps, which are based on the process of neoangiogenesis on autologous or allogenous tissue, such as the venous flow-through flap and integra flap. With this classification, we hope to help unify the classifications and, by doing so, facilitate the exchange of ideas, techniques and knowledge.MeSH terms: surgical flap / classification, terminology as topic.

Comparative Study of Collagen Density, Fibroblast, and Neovascularization in Tracheal Defect Reconstruction with Primary Repair and External Oblique Muscle Aponeurosis Patch (A Novel Study with New Zealand Rabbit)

Background: The lack of ideal materials and the high incidence of complications make tracheal defect reconstruction challenging. The use of aponeurosis as a surgical patch and flap in reconstruction is not uncommon, but no studies had been conducted to analyse its use in tracheal defect reconstruction, though its effectivity in wound healing was significant in reconstruction of other organs. Objective: This study aims to compare collagen density, fibroblast expression, and neovascularization in tracheal defect reconstruction using primary suture and using external oblique muscle aponeurosis patch. Methods: This randomized control trial is a laboratory experimental study using male New Zealand white rabbits. Randomization was carried out with permuted block randomization into a control group (primary suture) and a treatment group (reconstruction with external oblique muscle aponeurosis patch). Mascroscopic and histopathological assessments were carried out 14 days after surgery. Results: We got homogeneous samples in both groups (9 samples each) in terms of age (p = 0.763), weight before procedure (p = 0.347), and weight after procedure (p = 0.536). Macroscopically, no wound dehiscence, pus, or inflammation at the surgical site in either the control or treatment groups. Histopathological analysis showed that there were no differences in collagen density (p = 1.00), fibroblast expression (p = 0.414), and neovascularization (p = 0.558) between the two groups. Conclusion: It can be concluded that there are no differences in collagen density, fibroblast expression, and neovascularization in New Zealand rabbits with tracheal defect using primary suture and using external oblique muscle aponeurosis patch

Simplified Flap Approximation Approach for Second-Stage Implant Surgery in The Maxillary Jaw

Aim: The current publication presents a simplified surgical approach that allows easy adaptation of a flap in the upper jaw in second stage surgery in dental implants. Methods: A detailed step-by-step description of the simplified flap approximation approach is detailed with a graphical illustration of the surgical principles of the approach. Also, two clinical cases of the method are presented. Results: The simplified flap approximation approach allows easy flap adaptation that promotes primary healing of soft tissue around implants. Discussion: The simplified flap approximation approach allows an easy-to-manage surgical flap that optimizes soft tissue healing around implants in the second stage of surgery.

Pedicled omental flaps for complex wound reconstruction following surgery for primary spine tumors of the mobile spine and sacrum.

Surgery for primary tumors of the mobile spine and sacrum often requires complex reconstruction techniques to cover soft-tissue defects and to treat wound and CSF-related complications. The anatomical, vascular, and immunoregulatory characteristics of the omentum make it an excellent local substrate for the management of radiation soft-tissue injury, infection, and extensive wound defects. This study describes the authors' experience in complex wound reconstruction using pedicled omental flaps to cover defects in surgery for mobile spine and sacral primary tumors. A retrospective cohort analysis was conducted on 34 patients who underwent pedicled omental flap reconstruction after en bloc resection of primary sacral and mobile spine tumors between 2010 and 2020. The study focused on assessing the indications for omental flap usage, including soft-tissue coverage, protection against postoperative radiation therapy, infection management, vascular supply for bone grafts, and dural defect and CSF leak repair. Patient demographic characteristics, tumor characteristics, surgical outcomes, and follow-up data were analyzed to determine the procedure's efficacy and complication rates. From 2010 to 2020, 34 patients underwent pedicled omental flap reconstruction after en bloc resection of sacral (24 of 34 [71%]) and mobile spine (10 of 34 [29%]) primary tumors, mostly chordomas. The patient cohort included 21 men and 13 women with a median (range) age of 60 (32-89) years. The most common indication for omental flap was soft-tissue coverage (20 of 34 [59%]). Other indications included protecting abdominopelvic organs for postoperative radiation therapy (6 of 34 [18%]), treating infections (5 of 34 [15%]), providing vascular supply for free fibular bone graft (1 of 34 [3%]), and repairing large dural defects and CSF leak (2 of 34 [6%]). The median (range) follow-up was 24 (0-132) months, during which 71% (24 of 34) of patients did not require additional surgery for wound-related complications. At last follow-up, 59% (20 of 34) had stable disease and 32% (11 of 34) had recurrence, had progression of disease, or had been discharged to hospice after treatment. The pedicled omentum is an effective local tissue graft that can be used for complex wound reconstruction and management of high-risk closures in primary spine tumors. This technique may have a lower rate of complications than other approaches and may influence surgical planning and flap selection in challenging cases.

REGENERATIVE PERIODONTAL TREATMENT AS MANAGEMENT OF CHRONIC PERIODONTITIS: A CASE REPORT

Introduction: Chronic periodontitis is a chronic inflammatory disease induced by microbes beginning with inflammation of the gingiva and progressing to progressive damage to the tooth supporting structures. Various approaches have been made to treat chronic periodontitis, one of which is regenerative periodontal treatment using bone grafts and platelet-rich fibrin (PRF). History and Clinical Findings: A 32-year-old man came to the Periodontology Department of the Dental and Oral Education Hospital with chief complaints mobility of upper and lower teeth. Clinical examination showed that patient did not have a history of systemic diseases and the patient did not smoke. Intraoral examination showed that the maxillary front teeth grade 1 mobility and the average pocket depth in the maxillary and mandibular anterior teeth was 5 mm. Case Management: Case management includes initial therapy followed by surgical treatment which includes open flap, placement of bone graft and PRF, followed by frenectomy, then suturing and application of a periodontal pack. At 1 month after treatment, the surgical flap phase was continued for the mandibular anterior teeth using a combination of bone graft and membrane placement. Discussion: Bone graft and PRF are used to regenerate furcation defects and their ability to regenerate hard and soft tissue is due to the release of various growth factors. Conclusion: Regenerative surgical treatment in chronic periodontitis patients provides effective results in alveolar bone regeneration and decrease pocket depth.

Stage III Grade A Mandibular Anterior Tooth Periodontitis Treatment

Chronic periodontitis is inflammation caused by periodontopathogenic microorganisms characterized by alveolar bone resorption, loss of attachment and apical migration of junctional epithelium. Non-surgical and surgical periodontitis treatments including curettage are performed to reduce inflammation and form new attachments before flap surgery. The purpose of this writing is to treat periodontitis before flap surgical treatment is carried out. Case report: Female, 39 years old, came to RSGM UMY with complaints of loose lower front teeth and gums that bleed easily when brushing her teeth. The patient had no history of systemic disease. Intra-oral examination at the first visit revealed that the gingiva of the mandibular anterior teeth was reddish, unstippling and loose texture grade 2, OHI 7.3 (poor), PD 8 mm, PI score 30%, CAL 8 mm, and 3 tooth loss due to periodontitis. X-ray results showed resorption of the alveolar bone horizontally in the apical 1/3. DHE treatment plan, scaling and root planning, occlusal adjustment, splinting, curettage, flap surgery. Results: Control 2 weeks after curettage, gingiva was coral pink and PD was reduced. Conclusion: Curettage treatment in periodontitis cases reduces the depth of periodontal pockets and there are changes in clinical attachment levels (CAL) in mandibular anterior teeth. Surgical flap treatment is required in this case after curettage

Transfection of hypoxia-inducible factor-1α mRNA upregulates the expression of genes encoding angiogenic growth factors

Hypoxia-Inducible Factor-1α (HIF-1α) has presented a new direction for ischemic preconditioning of surgical flaps to promote their survival. In a previous study, we demonstrated the effectiveness of HIF-1a DNA plasmids in this application. In this study, to avoid complications associated with plasmid use, we sought to express HIF-1α through mRNA transfection and determine its biological activity by measuring the upregulation of downstream angiogenic genes. We transfected six different HIF-1a mRNAs–one predominant, three variant, and two novel mutant isoforms–into primary human dermal fibroblasts using Lipofectamine, and assessed mRNA levels using RT-qPCR. At all time points examined after transfection (3, 6, and 10 h), the levels of HIF-1α transcript were significantly higher in all HIF-1α transfected cells relative to the control (all p < 0.05, unpaired Student’s T-test). Importantly, the expression of HIF-1α transcription response genes (VEGF, ANG-1, PGF, FLT1, and EDN1) was significantly higher in the cells transfected with all isoforms than with the control at six and/or ten hours post-transfection. All isoforms were transfected successfully into human fibroblast cells, resulting in the rapid upregulation of all five downstream angiogenic targets tested. These findings support the potential use of HIF-1α mRNA for protecting ischemic dermal flaps.

Pedicled Peroneus Brevis Muscle Flaps as an Alternative to Fasciocutaneous Rotational Flaps for Lower-Extremity Soft Tissue Defects.

To report our experience using a peroneus brevis flap (PBF) for soft tissue defects of the distal third of the tibia, ankle, and hindfoot in resource-challenged environments. Retrospective review. Rural outpatient surgical facility in Honduras. Patients who sustained tibia, ankle, or hindfoot fractures or traumatic degloving, with critical-sized soft tissue defects treated with either a proximally based or distally based pedicled PBF to achieve coverage of the middle and distal third of the leg, ankle, and/or hindfoot. Flap healing, complications, and reoperations. Twenty-three patients, 4 with proximally based and 19 with distally based PBF flaps were included. The mean patient age was 37.3 (SD = 18.3; range 18-75 years). Duration of follow-up averaged 14.7 months (SD = 11.4; range 4-46). The PBF successfully covered the defect without the need for additional unplanned surgical flap coverage in all but 2 patients. Thirty percent of the PBFs received a split thickness skin graft, while the remainder granulated successfully without skin graft. Four flaps were partially debrided without additional flap mobilization, while 1 flap was lost completely. Ten patients had successful re-elevation of their flaps for secondary procedures such as implant removal, spacer exchange, deep debridements, and bone grafting. All donor site incisions healed without complication. The pedicled PBF allows coverage of distal leg, ankle, and hindfoot wounds using muscle in patients who may otherwise require free tissue flaps or transfer to another institution for coverage. PBFs can be learned and implemented without the use of microvascular techniques. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.