Tension-free Primary Closure Research Articles

The Efficacy of Naso-Alveolar Molding on Premaxilla Pushback and Dentoalveolar Changes in Patients With Bilateral Cleft Lip and Palate.

To evaluate the extent of naso-alveolar molding (NAM) in pushing the premaxilla posteriorly in patients with bilateral cleft lip and palate (BCLP). Naso-alveolar molding application in cleft lip and palate cases bridges the cleft gap and increases nasal tip projection. In BCLP, NAM potentially mobilizes the premaxilla posteriorly to allow tension-free primary lip closure. However, some patients with BCLP with NAM history still necessitate osteotomy during labioplasty, questioning the efficacy of NAM for BCLP management. This single-center retrospective study was conducted using medical records of nonsyndromic patients with BCLP. Twenty-six patients with BCLP were enrolled over a 5-year period with a history of NAM application before primary labioplasty. The changes in premaxilla width (P), anterior arch width (A), posterior arch width (R), and anteroposterior projection of the premaxilla (P'-A') were statistically analyzed at 2 time points: (1) at the start of NAM application (T1) and (2) after completion of NAM before surgery (T2). The average age at NAM initiation was 46.2 ± 40.4 days, and the average duration of NAM usage was 125.14 ± 62.94 days. A and P-A showed significant differences between T1 and T2 (P < 0.0001), whereas the rest did not show significant differences in value following NAM application (P > 0.05). Naso-alveolar molding successfully pushed back the premaxilla portion about 4.68 ± 2.83mm on average. Naso-alveolar molding can push back the premaxillary protrusion up to 5mm, which can serve as a cutoff point for the consideration of combined modalities. Prenatal diagnosis, counseling, and cleft education should be the benchmark in cleft centers to improve overall patient outcomes.

Management of the Lingual Flap During Vertical Augmentation of the Atrophic Anterior Mandible: Anatomical Overview and Description of the Technique.

Vertical ridge augmentation in the anterior mandible is a technically delicate procedure that requires knowledge of some anatomical structures to reduce intra- and postoperative complications. Proper soft tissue management is one of the primary aspects to the success of these techniques, enabling tension-free primary wound closure and preventing membrane exposure. This cadaveric and clinical study provides an anatomical overview of the lingual portion of the anterior mandible. Moreover, there is a description of a novel surgical approach for release of the lingual flap that will help clinicians achieve primary closure without incurring intrasurgical complications.

A Review on Intraoral Soft Tissue Expanders: A Novel Technique for Tissue Augmentation Prior to Treating Ridge Defects

Periodontitis, is a complex infectious disease resulting in destruction of tooth supporting structures, which gradually may result in bone loss. Common complications of ridge augmentation procedures are soft tissue dehiscence and attaining a tension free primary closure after grafting. Soft tissue expanders provide a novel alternative to invasive, tedious methods of soft tissue augmentation by gradually increasing the volume and thickness of soft tissues, before ridge augmentation. This is a short review article on the available soft tissue expanders and their benefits on achieving a proper ridge morphology.

The Use of Flap Techniques to Preserve Limb Length in Patients with Transmetatarsal Amputations.

Chronic lower extremity wounds affect up to 13% of the US population. Transmetatarsal amputation (TMA) is frequently performed in patients with chronic forefoot wounds. TMA allows limb salvage and preserves functional gait, without need for prosthesis. Traditionally, when tension-free primary closure is not possible, a higher-level amputation is performed. This is the first series to evaluate the outcomes of local and free flap coverage of TMA stumps in patients with chronic foot wounds. A retrospective cohort of patients who underwent TMA with flap coverage from 2015 through 2021 was reviewed. Primary outcomes included flap success, early postoperative complications, and long-term outcomes (limb salvage and ambulatory status). Patient-reported outcome measures using the Lower Extremity Functional Scale (LEFS) were also collected. Fifty patients underwent 51 flap reconstructions (26 local, 25 free flap) after TMA. Average age and body mass index were 58.5 years and 29.8 kg/m 2 , respectively. Comorbidities included diabetes [ n = 43 (86%)] and peripheral vascular disease [ n = 37 (74%)]. Flap success rate was 100%. At a mean follow-up of 24.8 months (range, 0.7 to 95.7 months), the limb salvage rate was 86.3% ( n = 44). Forty-four patients (88%) were ambulatory. The LEFS survey was completed by 24 surviving patients (54.5%). Mean LEFS score was 46.6 ± 13.9, correlating with 58.2% ± 17.4% of maximal function. Local and free flap reconstruction after TMA are viable methods of soft-tissue coverage for limb salvage. Applying plastic surgery flap techniques for TMA stump coverage allows for preservation of increased foot length and ambulation without a prosthesis. Therapeutic, IV.

The Significance of Mylohyoid Muscle Release (MMR) in the Vertical and Horizontal Ridge Augmentation Surgeries; Clinical and Human Cadaver Analyses of the Techniques

(1) Background: Ridge augmentations either horizontal (HRA) or vertical (VRA) in the posterior mandible are very challenging regenerative procedures. To attain and retain tension-free primary closure, buccal periosteal and mylohyoid muscle releases should be performed. The purpose of the present study was to review, analyze and discuss the three different techniques for the mylohyoid muscle release (MMR) in VRA and HRA surgeries on a clinical and human cadaver level. (2) Presentation of the techniques: Three different techniques are described in the literature regarding the lingual flap management: (i) the finger sweep technique (FST), (ii) the release of the mylohyoid muscle attachment on the lingual flap (MMALF), and (iii) the mylohyoid preservation technique (MPT) in three key anatomical zones. All three techniques, even though they use a different approach, can achieve similar amount of horizontal and vertical mylohyoid muscle release although MPT showed statistically significant higher flap advancement. The human cadaver analyses revealed that all three techniques are considered safe since they do not approximate vital anatomical structures. (3) Conclusions: All three techniques are considered safe, but they are not free of limitations or complications; therefore, they should be performed only by highly experienced and trained clinicians. MPT achieved statistically significant higher flap advancement.

Comparative Assessment of Flap-Advancing Techniques in an Ex Vivo Cadaverous Porcine Model.

Since flap advancement is a prerequisite for tension-free primary closure and successful regenerative procedures, the aim of this study was to test the efficacy of six surgical approaches for flap advancement in an ex vivo porcine model. A total of 60 fresh mandibles from pigs were randomized into one of six groups: (1) trapezoidal full-thickness flap design with two vertical releasing incisions (control), (2) trapezoidal flap with linear periosteal scoring, (3) mucosal detachment technique, (4) mucosal detachment with horizontal extension, (5) mucosal detachment with horizontal and vertical extension, and (6) mucosal detachment with horizontal vertical and cutback extension. Coronal advancement of the flap was recorded as the primary variable; the surface area of exposed mucosa and the tear strength were recorded as secondary variables. Homogeneity existed among groups for preoperative keratinized tissue width and tissue thickness. Mucosal detachment with horizontal, vertical, and, cutback extensions achieved the highest amount of advancement. All remaining groups achieved a statistically higher advancement compared with the trapezoidal full-thickness flap (control). Pairwise comparison demonstrated statistical significance between any two groups (P < .001). A positive correlation was noted between exposed mucosa and flap advancement; the advancement increased 0.62 mm for each 10 mm2 of increase in the exposed mucosal surface. Strength at tear stress was the highest in the trapezoidal full-thickness flap (control) and mucosal detachment with horizontal-vertical-cutback incisions (P < .001). Coronal flap advancement was maximized in the mucosal detachment techniques and positively correlated with the area of exposed mucosa.

An Integrated Surgical Management for Giant Dermatofibrosarcoma Protuberans of Anterior Abdominal Wall

Giant dermatofibrosarcoma protuberans (DFSP) is a very rare dermal sarcoma whose diagnosis and management are important because of the high local recurrence but low metastatic potential. Complete surgical excision of giant DFSP in a single stage is difficult but has a high cure rate.A 47-year-old man presented with a gradually increasing large (18 x 15 x 7 cm) DFSP in the epigastrium. A 3 cm circumferential wide local excision (WLE) with microscopic tumor-free margin confirmed by frozen section was performed. Immediate single staged tension-free primary closure of resultant defect was done on the principle of abdominal wall reconstruction (AWR) in ventral hernia repair. This technique of anterior component separation and bridge meshplasty is functional, avoids multiple surgeries, is cost-effective, and can be done in a resource-limited setting in developing countries.A multidisciplinary and integrated surgical approach to treat giant DFSP over epigastrium, by three-dimensional WLE and immediate AWR with anterior component separation technique (CST) and bridging meshplasty, can be of immense help in managing such rare cases in developing countries.

Mucosal Detachment Technique for Flap Advancement in a Thin Tissue Phenotype: Technique Illustration

Passive-tension flap closure of primary wounds remains the most important factor for achieving predictable bone augmentation outcomes. So far, no specific surgical technique has been proposed for major flap advancement, specifically in the thin tissue phenotype (≤ 1.5 mm thick). This article illustrates a detailed description of the Mucosal Detachment Technique (MDT), which separates the mucosal tissue from the underneath periosteum and aims to achieve adequate flap flexibility to cover high-volume augmentation in the thin tissue phenotype. Separating the mucosa from the periosteum allows maintenance of vascularization and an even distribution of tension among the advanced flap. The MDT allows bone augmentation procedures in thin tissue phenotype flap. The flap advancement permits tension-free primary closure in all tissue phenotypes (both thin and thick), independent of the degree of volume augmentation.

The Triangular Dart Flap: A Reconstructive Option for Soft Tissue Defects.

Reconstruction of soft tissue defects after skin cancer excision remains a challenge. Options for reconstruction are numerous, including primary repair, local tissue rearrangement, and skin grafts, among others. In this series, the authors present a novel technique: The triangular dart flap. This is a single-stage tissue rearrangement that uses the redundant tissue of the dog-ear to aid in the closure of these wounds. A retrospective review was conducted of all patients undergoing local tissue rearrangements by the senior author from 2009 to 2018. Factors were collected and analyzed, including age, size and cause of defect, comorbidities, smoking history, and postoperative complications. Twenty-four patients underwent reconstruction with a triangular dart flap for repair of malignant defects. Mean defect size was 7.3 cm2 (0.8-20 cm2), and mean repair size was 29.7 cm2 (6-80 cm2). Initial pathology included basal cell carcinoma (45.8%), melanoma in situ (29.2%), and squamous cell carcinoma (16.7%), among others. Location varied widely among face and extremities. Anesthesia was predominantly local only (79.1%). There were no major complications, and 5 (20.8%) minor complications. The triangular dart flap is a novel single-stage procedure, generally performed under local anesthesia only, for correction of Mohs defects. By using the redundant tissue of dog-ears to better approximate the wound edges, a tension-free primary closure can be achieved in sensitive areas, such as the nasal tip.

Closure of Challenging Pediatric Scalp Wounds by a Tension-Relief System.

Pediatric scalp defects may be challenging, due to their variant tension level and specific etiologies. Tissue characteristics and pre- and post-management considerations may pose difficulties to reconstruction in the pediatric patient. Primary closure is the preferred surgical technique but is not always possible. Various techniques have been described for facilitating primary wound closure, by reducing tension from the skin wound margins. The authors use a tension-relief system in some challenging scalp wounds when simple primary closure cannot be achieved. This enables primary closure without tension on the surgical margins, and may thus preclude the need for other closure techniques such as tissue-expanders, grafts, and flaps. The authors describe our use of a tension-relief system in 21 pediatric patients treated during 2017-2020, for congenital deformities, vascular malformations and other skin lesions, traumatic wounds, burn scars, and complicated surgical wounds with and without hardware exposure. A tension-relief system is a prompt, simple-to-use, safe, and low-cost surgical solution that offers several advantages over other techniques when tension-free primary intention closure is not possible. These benefits include less extensive surgery, fewer surgeries and associated anesthesia, shorter treatment period and hospitalization, better scarring, lower distress and burden to patients and their families, better pain-control, the absence of donor-site with its comorbidities, and less bleeding and risk of damaging adjacent structures. Based on our experience and the system characteristics detailed, the authors recommend using the described technique, which is convenient, accessible, and reliable, to close challenging scalp wounds in pediatric patients.

Comparison of Karydakis Flap versus Tension-Free Primary Midline Closure in Pilonidal Sinus Treatment

Comparison of Karydakis Flap versus Tension-Free Primary Midline Closure in Pilonidal Sinus Treatment

Guided bone regeneration.

Guided bone regeneration (GBR) is a surgical procedure that utilizes bone grafts with barrier membranes to reconstruct small defects around dental implants. This procedure is commonly deployed on dehiscence or fenestration defects ≥2 mm, and mixing with autogenous bone is recommended on larger defects. Tension-free primary closure is a critical factor to prevent wound dehiscence, which is critical cause of GBR failure. A barrier membrane should be rigidly fixed without mobility. If the barrier is exposed, closed monitoring should be utilized to prevent secondary infection.

The Role of Autologous Platelet Concentrates in the Treatment of Medication-Related Osteonecrosis of the Jaw.

The frequent refractory response of patients to the treatment of medication-related osteonecrosis of the jaw (MRJON) has attracted clinicians' attention to several treatments. However, they are at best, palliative, and have a higher failure rate than previous treatments. The present meta-analysis was performed to evaluate the clinical effectiveness of autologous platelet concentrates (APCs) combined with surgery in the treatment of MRONJ. The authors conducted a meta-analysis involving a systematic search of PubMed, EMBASE, Wiley Online Library and the Cochrane Library for eligible studies from their inception to November 2019, in accordance with preselected criteria. The inverse variance method was applied to fixed or random effects models based on the heterogeneity of the studies. Thirteen studies that investigated APCs in the treatment of MRONJ were eligible for inclusion in the meta-analysis of 223 patients and 33 lesions. The pooled success rate of APCs combined with surgery for MRONJ was 90% (95%CI, 80%-97%) and the pooled OR was 7.67 (95%CI, 2.10-27.98), indicating the combination was 7.67 times more effective than surgery alone. The results suggest that the use of APCs is a promising therapeutic regimen, as it provided additional benefits to surgery in the treatment of MRONJ. To achieve the benefits, a tension-free primary closure of the soft tissue is recommended as well. Randomized studies with large sample sizes is warranted to confirm our finding.

Selection and effects of flap/myocutaneous flap repair methods for the defect after perineum tumor resection

Objective: To explore the selection and effects of flap/myocutaneous flap repair methods for the defect after perineum tumor resection. Methods: From January 2011 to February 2017, 31 patients with vulvar tumor who were admitted to Hunan Cancer Hospital underwent repair of wound after tumor resection with various flaps/myocutaneous flaps. The patients were composed of 5 males and 26 females, aged 39-76 years, with 27 vulvar cancer and 4 Paget's disease in primary diseases. The size of defects after vulvar tumor radical resection ranged from 8.0 cm×4.5 cm to 27.5 cm×24.0 cm. According to the theory of perforasome, the defects were repaired by the external pudendal artery perforator flap, deep inferior epigastric artery perforator flap, rectus abdominis myocutaneous flap, anterolateral thigh flap, internal pudendal artery perforator flap, gracilis myocutaneous flap, and profunda artery perforator flap based on the specific size and location of perineum and groin where the defect was located. According to the blood supply zone of flap, totally 17 local translocation flaps, 18 axial flaps/myocutaneous flaps, and 7 V-Y advancement flaps were resected, with an area of 7.0 cm×4.0 cm to 21.0 cm×13.0 cm. All the flaps/myocutaneous flaps were transferred in pedicled fashion, and the donor sites were closed without tension. The number of flaps/myocutaneous flaps, wound closure, flaps/myocutaneous flaps survival, and follow-up were observed and recorded. Results: Altogether 42 flaps/myocutaneous flaps were harvested in 31 patients. Two flaps/myocutaneous flaps were used in 11 cases for large circular defect repair. All the defects achieved tension-free primary closure. The blood supply of 32 flaps/myocutaneous flaps was good, while insufficient blood supply was noted in the other 10 flaps/myocutaneous flaps. Seventeen flaps/myocutaneous flaps survived smoothly. Wound dehiscence occurred in 5 flaps/myocutaneous flaps 8 to 14 days postoperatively, which was healed with dressing change. Temporary congestion was noted in 7 flaps/myocutaneous flaps 2 to 5 days postoperatively, which recovered without special treatment. Three flaps/myocutaneous flaps had infection 7 to 15 days postoperatively, two of which recovered after dressing change, while the other one had partial necrosis and received debridement and direct closure. Two flaps/myocutaneous flaps were totally necrotic 8 to 15 days postoperatively, which were repaired with pedicled rectus abdominis myocutaneous flap after debridement. Seven flaps/myocutaneous flaps had partial necrosis 7 to 20 days postoperatively and were healed after dressing change. Twenty-four patients were followed up for 9-38 months. The color of flaps/myocutaneous flaps was similar to that of the surrounding skin, the shape of vulva was natural, the movement of hip joint was not limited, the function of micturition and defecation was not affected, and tumor recurrence was noted in 3 patients. Conclusions: For the complicated large defect after perineum tumor resection, the flexible application of different forms of flaps/myocutaneous flaps to repair according to different areas regains the appearance and function. However, there are many complications, so it is necessary to further strengthen the postoperative care.

Sequential propeller flaps in the treatment of post-traumatic soft tissue defects of the lower limb – a case series

IntroductionPropeller flaps have gained great popularity among reconstructive surgeons; however, the inability to directly close the donor site of large propeller flaps constitutes a well-known limitation of this technique. Skin grafting of the donor area is not always feasible nor desirable. To address large propeller flaps secondary defects, we investigated the use of a second propeller flap harvested from a nearby region of relative skin redundancy to assist the donor site closure generated by the first. Since the donor defect of the second flap is closed by direct suture, the aim of this “sequential” propeller flaps technique is to achieve complete, like-with-like, soft tissue restoration while avoiding skin grafting. MethodsFrom April 2018 to September 2019, eight patients presenting post-traumatic soft tissue defects were planned to be reconstructed by means of the sequential propeller flaps technique, for a total of 16 propeller flaps. The locations of the defects included the distal leg in four cases, the heel in two cases, the proximal lateral thigh in one case and proximal posterior thigh in the remaining one. All the flaps but one were harvested as a perforator-based propeller type and rotated by different degrees around the skeletonized perforator. In one patient, due to an intraoperative complication following the first flap harvest, the harvest of the second flap was abandoned. ResultsIn all but one patient, a complete, tension free primary closure of all wounds was achieved without complications, the functional recovery as well the esthetic outcome were excellent. One patient showed intraoperative signs of vascular insufficiency involving 15% of the first flap. The plan of harvesting the second flap was intraoperatively abandoned and the definitive wound closure with a free muscle gracilis was carried out the following week. ConclusionIn some selected cases, the use of multiple propeller flaps performed in sequence allows the surgeon to obtain complete, like-with-like wound closure with vascularized tissue avoiding a free tissue transfer procedure, however, it requires a vast experience with propeller flaps and meticulous preoperative planning.

Freestyle Perforator Puzzle Flap for Posterior Trunk Reconstruction.

Closure of extensive defects of posterior trunk can be challenging for reconstructive surgeons owing to the need of a large bulk of well-vascularized tissue to resurface the skin and the exposed hardware and to fill the dead spaces. We hypothesized that elevating multiple perforators flaps in various patterns would allow for reconstruction of large posterior trunk defects with tension-free primary closure and minimal donor site morbidity. Between January 2013 and December 2016, 23 patients with large posterior trunk defects underwent reconstruction with a multiple freestyle perforator flaps approach. We experimented a freestyle perforator-based reconstruction, which consists of designing a sequence of flaps, able to adequately fit the defects, allowing for tensionless primary closure. The average age of patients was 60.2 years (range, 18-80 years). A total number of 62 perforator flaps was performed, with an average of 2.6 flaps per patient. We were able to successfully cover defects up to 27 × 29 cm. A single perforator was used in 58 flaps, whereas more than 1 perforator was applied in 4 flaps. In all cases, the donor sites were closed primarily, and patients healed uneventfully. Six patients underwent radiotherapy after surgery, but no complication occurred. In this series of extensive defects of the posterior trunk, a tension-free closure was achieved by distributing the tension to multiple freestyle perforator flaps, supplying sufficient volume of tissue and reliable vascularization. This approach can be a valid tool in facing reconstruction of large and complicated defects of the posterior trunk.

Excision and tension-free primary closure of pilonidal disease.

This study aimed to estimate simple excision and tension free primary closure and to study its effectiveness in terms of operating and healing time, duration of hospital stay, degree of post operation complications, and rate of recurrence. This is study included 78 patients, of whom 71 were (91%) males and 7 (9%) females, who underwent excision and tension free closure. The procedure was based on bilateral side flaps, which were released and dissected 2-3 cm from the edge of the wound. Patient's age, gender, body mass index, wound healing, operation, drain removal, length of hospital stay, and complications and recurrence were analysed. The study involved 78 patients, 71 (91%) males and 7 (9%) females. Median age of the patients was 28.5 years. Mean operation time was 44.6 minutes . Sixty-one patients (78.2%) had full primary healing without any complication. No one had hematoma or seroma, but five (6.4%) cases had a minor wound infection and three (3.8%) obese patients developed recurrence. Mean length of hospital stay was 2.5 days , most patients went back to their work within 3 weeks. Median follow-up period was in a 26.2 weak range (1-51.4 weak). Five (6.41%) cases had wound infection and three (3.85%) developed recurrence. Excision and tension free primary closure were found to be simple procedures associated with lower rates of wound infection, shorter hospital stay, lower recurrence, early wound recovery and short period of being absent from work. Surgery can be easily performed and preferred for cases of non-recurrent pilonidal sinus and cyst.

Robotic ventral hernia repair: a safe and durable approach.

Short-term success following robotic-assisted ventral hernia repair (RVHR) is well established; however, data describing outcomes after the first year are limited. In this study, we followed a cohort of patients with an average of 1.8years of follow-up to demonstrate the durability of this technique and examine risk factors for recurrence. A retrospective analysis of RVHR performed by a single surgeon from 2012 to 2016 was done. The technical approach for hernia repair consisted of tension-free primary fascial closure with placement of preperitoneal mesh when possible. The primary end point of hernia recurrence was determined based on physical examination or imaging documented in the medical record. A logistic regression model was used to identify patient risk factors for recurrence. One hundred and eight RVHRs were performed over 4years. Mean age was 52.72 ± 13.61years, BMI was 33.07 ± 7.82kg/m2, and hernia defect size was 70.1 ± 86.3 cm2. In terms of patient characteristics, 17.6% of patients were diabetic, 13.9% were smokers preoperatively, 72.2% were ASA class 3 or higher, and 29.6% had prior VHR. Primary fascial closure was achieved in all RVHRs, with 23.1% requiring component separation. Mesh was used in 97.2% of patients: 79.5% had preperitoneal mesh and 17.6% had intraperitoneal onlay mesh. Ninety-eight percent of patients had long-term follow-up at a mean of 625.6days. Recurrence rate was 12%, with one recurrence attributed to an inguinal hernia fixed concurrently with a midline defect. There were no statistically significant differences in gender, age, BMI, ASA class, incidence of diabetes, smoking status, or number of previous hernia repairs. Hernia defect size and perioperative complications including SSO, ileus, obstruction, or any other medical complication were not predictive of recurrence. Technical approach did not affect outcomes. RVHR is safe and durable with a low recurrence rate at a mean of 21months postoperatively. Patient characteristics or type of repair were not predictive of recurrence.

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

Aim: Free tissue transfer is essential for extremity reconstruction following traumatic injuries, oncologic resection, and diabetic complications. However, given the circumferential shape of the arm and leg, a small amount of ongoing edema can prevent a tension-free closure. Additionally, intraoperative thrombosis, vascular disease can lead to proximal exposure of the pedicle or vein grafts. This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle, in comparison with a matched cohort with a tension-free primary closure.

Prelamination of the latissimus dorsi flap for reconstruction in head and neck surgery

Free microsurgical tissue transfer of the latissimus dorsi flap may be indicated for the restoration of intra- and extraoral defects, especially when a large-sized skin island flap is required. In many cases, use of the latissimus dorsi flap for coverage of large-sized intraoral defects results in bulkiness due to the proportion of subcutaneous fat. Prelamination of free flaps appears to be a promising technique to overcome this flap bulkiness. This modification in flap design could improve the postoperative functional outcome, as well as reduce donor site morbidity. This article presents four novel clinical cases, in which the patients underwent prelamination of the latissimus dorsi flap with local skin grafts during oral cancer treatment in order to reduce the thickness of the free flap and allow tension-free primary closure of the donor site. These attempts successfully covered large-sized intraoral defects, achieving good functional outcomes with minimal donor site morbidity.