U-shaped Flap Research Articles

Immediate Nipple Reconstruction in Skin-sparing Mastectomy with A Modified Wise-pattern Design.

This article discusses a novel approach to immediate nipple reconstruction during skin-sparing mastectomy with Wise-pattern design, a common procedure in direct-to-implant breast reconstruction. Traditionally, nipple reconstruction is performed as a second procedure, incurring additional costs and potential complications. This novel technique involves a simple modification to the Wise-pattern flap during the initial mastectomy, allowing for one-step reconstruction. The procedure includes preoperative markings of the Wise-pattern design, with a U-shaped flap added at the top angle to create the nipple position. This U-shaped flap, containing both skin and subcutaneous tissue, is then folded over itself and sutured, resulting in an inverted T-shaped incision with the reconstructed nipple at the apex. This article emphasizes the avoidance of a secondary operation for nipple reconstruction, avoiding additional costs and potential complications associated with flap loss, especially in postradiation patients. The technique was applied to five consecutive cases, with patient satisfaction reported as very high. Follow-up at 6 months showed no venous congestion or flap loss, and in patients without adjuvant radiation, the reconstructed nipple maintained almost all its initial postoperative height. Minor loss of nipple protrusion over time was comparable to traditional nipple reconstruction (eg, skate flap), and the construction of the new nipple required only an average of 10 extra minutes. Although larger-scale studies are needed for a comprehensive evaluation, the preliminary results suggest promising outcomes and encourage larger-scale safety and outcomes studies of this technique in Wise-pattern skin-sparing reconstructions.

Internal urethral sphincter reconstruction with anterior bladder neck tube for robotic and laparoscopic radical prostatectomy: improving early return of continence.

In recent years, despite several surgical techniques having been applied, the early incontinence rate after radical prostatectomy (RP) remains high. In this study, we reconstructed an internal urethral sphincter (IUS) with anterior bladder neck tube (ABNT) to improve early return of continence and find a more effective technique for early urinary incontinence after RP. In this study, 96 previous patients who did not receive an ABNT between October 2018 and May 2020 were compared as historical controls (the control group). A total of 210 consecutive patients underwent robotic or laparoscopic RP with ABNT between May 2020 and February 2023 (the ABNT group). The inclusion criteria included Eastern Cooperative Oncology Group (ECOG) score 0-1 and localized prostate cancer (clinical stages cT1-3, cN0, cM0). The exclusion criteria included patients with diabetes, neurologic diseases, previous pelvic operations, symptoms of urinary incontinence, prior radiation, focal therapy, or androgen deprivation therapy for prostate cancer. ABNT was reconducted with a U-shaped flap from the anterior wall of the bladder neck, and was then anastomosed with the urethra. In the control group, the bladder outlet was directly anastomosed with the urethra. Continence, as defined if 0 pads were used per day and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score ≤6, was assessed at 1, 4, 8, 12, and 24 weeks after catheter removal. At 2 weeks after catheter removal, urethral pressure profilometry (UPP) and upright urethrography were performed to evaluate the function of ABNT in the ABNT group. More patients in the ABNT group were continent than those in the control group at 1 week (85.2% vs. 22.9%, P<0.001), 4 weeks (91.4% vs. 27.1%, P<0.001), 8 weeks (95.2% vs. 40.6%, P<0.001), 12 weeks (100% vs. 71.9%, P<0.001), and at 24 weeks (100% vs. 87.5%, P<0.001) after catheter removal. Stricture was presented in 5.2% and 2.1% (P=0.34) in the ABNT group and control group, respectively. UPP showed that a functional IUS was reconstructed with ABNT. Upright urethrography showed that the ABNT was filled with contrast medium in the urination period and with no contrast medium during the storage period and interruption of urination. The ABNT technique significantly improved early return of continence in comparison with the no ABNT technique, especially the immediate continence. The ABNT technique reconstructed the functional IUS with acceptable urethral stricture. The limitations of the present study include that the comparison was conducted retrospectively with a historical cohort and lack of randomization, and the single center setting. A prospective, randomized, and multicenter evaluation is expected.

Comparison between Rolled and Nonrolled U-Shaped Flap in the Second Stage of Dental Implant Surgery: A Randomized Clinical Trial.

Background The presence of black triangles around the dental implant-supported prosthesis and the failure to construct adequate papillae around them bothers dental implantologists. Peri-implant surgical soft tissue management will improve esthetics, function, and implant survival. Aim To compare the effects of rolled and nonrolled U-shaped flaps combined with a temporary crown in enhancing the soft tissue around dental implants. Materials and Methods Forty patients were included in this study; all patients were operated on by the same maxillofacial surgeon at Al-Iraq specialized dental clinics from January 2019 to January 2020. Patients were divided randomly into two groups: group A: at the second stage of implant surgery, a U-shaped flap without rolling was used in conjunction with temporary crown placement; group B: at the second stage of implant surgery, a U-shaped flap with rolling was used in conjunction with temporary crown placement. Then, the temporary crown was fabricated for both groups and kept in place for one month. Two independent maxillofacial surgeons evaluated all patients two weeks after the cementation of the final zirconia crown for the implant soft tissue esthetic score. Results The highest possible score assigned to the mesial papilla (2 scores) was present in 92.5% of the group A patients and only 77.5% of the group B patients. Moreover, we have found that alveolar bone contour is achieved perfectly (2 scores) in 70% of group A patients but only in 32.5% of group B patients. Conclusion The U-shaped flap without rolling with a temporary crown is a simple technique. It has good results, especially when there is no severe resorption of the labial bone plate (in canine and premolar areas).

Use of a Rotational Flap with Soft Tissue Graft and Tunneling Technique for Ovate Pontic Site Development for a Highly Esthetic Outcome: A Case Report

The objective of therapy was to replace the missing teeth with a restoration that closely adhered to the natural teeth and soft tissue contour to provide an esthetic outcome. A 19-year-old male reported a failed fixed partial denture (FPD) in the maxillary left central incisor. The abutment extended to the maxillary right central incisor and the maxillary left lateral incisor. Radiographic examination revealed that the neighboring maxillary right central incisor abutment was nonrestorable. The treatment plan was the extraction of the maxillary right central incisor with socket preservation, modification of the pontic sites for placement of an ovate pontic for the replacement of the missing maxillary upper central incisors with an FPD with the maxillary lateral incisors serving as the abutment teeth. The pontic sites were corrected with a U-shaped flap extended 5 mm palatal from the mid-crestal line. The incision was avoided at the interdental papilla area. The facial flap was elevated. The facial soft tissue was vertically tunneled. The flap was flipped into the facial tunnel and stabilized with horizontal nylon matrix sutures. The surgical site was stabilized with a provisional FPD with an ovate pontic. The final restoration was a full zirconia facial veneered FPD. Surgical site showed significant healing with a natural emergence profile, and interdental papillae filling the gingival embrasure, showing no evidence of recession. At the 1-year follow-up, the gingival thickness improved and the pontic emergence profile was natural. A very stable result for soft tissue volume and interdental papillae were seen. According to the result obtained with rotational flap, it can be used for small anterior defects with promising results, without the need for bone graft procedures or additional tissue graft. With proper case selection, the use of a rotational flap with a tunnel technique and an ovate pontic in the anterior esthetic region is an alternative treatment option that can successfully restore masticatory and esthetic function.

U-shaped muscle flap video

U-shaped muscle flap video

The value of definitive perineal urethrostomy for the treatment of complex adult anterior urethral strictures

Objective To analyze the clinical outcome of definitive perineal urethrostomy for the treatment of complex adult anterior urethral strictures. Methods From June 2012 to February 2018, 28 patients who underwent the definitive perineal urethrostomy for a complex anterior urethral stricture were retrospectively reviewed. The mean age of the patients was 62.3 (range 34 to 77) years and stricture etiology was lichen sclerosus in 46.4%(13/28) of the cases, iatrogenic stricture after transurethral resection of the prostate in 35.7%(10/28), failed hypospadias repair in 10.7%(3/28), infection 3.6%(1/28) and idiopathic etiology 3.6%(1/28). The mean stricture length was 9.6 (range 4.5 to 16.0) cm and the stricture length 10 cm in 57.1%(16/28). Of 28 patients 21 (75%) underwent prior urethral dilation, 4 (14.3%) underwent direct vision internal urethrotomy (DVIU) and 17 (60.7%) underwent urethroplasty. Among the medical history of interest, hypertension was observed in 17 patients (60.7%), chronic ischemic heart disease in 11 patients (39.3%), diabetes mellitus in 9 patients (32.1%) and chronic obstructive pulmonary disease (COPD) in 9 patients (32.1%). All patients completed the perineal urethrostomy with inverted U-shaped perineal skin flap. The patient was placed in a normal lithotomy position and an inverted U-shaped perineal incision was made. We can get an inverted U-shaped perineal skin flap after dissecting along the bulbospongiosus muscle. The bulbar urethra was opened along the ventral surface and the margins of the spongiosum tissue were closed with perineal skin flap. We analyzed the clinical characteristics of the patients, the outcome of the technique and investigated the satisfaction rates of the patients by outpatient follow-up or telephone interview. Surgical success was defined as functional voiding without the need for further procedures. Results The perioperative complications included 3 cases of urinary tract infection, 1 case of bleeding and 1 case of wound dehiscence. Mean follow-up length was 27.2(range 6.0 to 64.0)months. Of 28 cases 26 (92.9%) were successful and the mean maximum urinary flow rate was 26.5(range 17.0 to 40.0)ml/s. Postoperatively, 2 cases of urethrostomy strictures were found in 2 months and 4 months, respectively. They required periodic outpatient dilation and the younger one was in the waiting list for revision of the perineostomy and the older one refused the revision. Of 28 patients 24 (85.7%) were satisfied with the results obtained with surgery, 15 were very satisfied, 9 cases satisfied and 4 cases dissatisfied. Conclusions The successful rate of the definitive perineal urethrostomy for the complex adult anterior urethral strictures was high and patients were satisfied with the outcome of the surgery. The definitive perineal urthrostomy is a well-tolerated treatment option for patients with complex anterior urethral strictures, especially for those aged and with extensive comorbidities. Key words: Urethral stricture; Anterior urethral; Perineal urethrostomy; Urinary diversion

Repair of skin and soft tissue defects of the extremity by transplantation of a U-shaped trimmed ilioinguinal flap

Objective To explore the efficacy of transplantation of a U-shaped ilioinguinal flap in the repair of skin and soft tissue defects of the extremity. An axial flap based on the superficial iliac circumflex artery and trimmed to a subdermal vascular network flap was used for the procedures. Methods Seven patients with skin and soft tissue defects treated between June, 2009 and May, 2014 were studied. The patients were 22-45 years of age (mean, 32 years) , and included 5 males and 2 females. Four patients had punch-press injuries, 1 patient had a hot-crush injury, and the remaining 2 patients were injured in the accidents. The wound sizes were 14.0 cm × 10.0 cm to 6.0 cm × 5.0 cm, with a varying extent of exposed tendons and bones. Repairs were performed using free ilioinguinal flaps, which were 15.0 cm × 11.0 cm to 7.0 cm × 5.0 cm in size. The axial flap was trimmed to a U-shaped subdermal vascular network flap and transplanted to the recipient site with anastomosis of blood vessels. Results All transplanted flaps survived. Four patients were followed for 1-6 months, with a mean duration of follow-up of 4 months. The trimmed flaps showed gradual reddening immediately after surgery, and the capillaries were recovered with a flat surface. Re-examination 3 months after surgery showed that the flaps were thin and flexible and met the aesthetic demand. No obvious pigmentation occurred, and the donor site was sutured directly, leaving only linear scars. Conclusion Repair of skin and soft tissue defects of the extremity using a U-shaped trimmed ilioinguinal flap has the advantages of a hidden donor site, small scar, and conformity to aesthetic requirements. The trimmed flaps are preferred over untrimmed flaps in terms of color and texture. The former flap is thinner, meets the aesthetic demand, and achieves a better efficacy. Key words: Ilioinguinal flap; Subdermal vascular network flap; Extremity; Microsurgical operation

A case of arterial switch operation with coronary elongation technique.

A 28-day-old infant with d-transposition of the great arteries underwent arterial switch operation. The coronary pattern was Yacoub type A, in which coronary transfer is usually thought to be easy. However, a dominant conus branch diverged from the proximal portion of the left coronary artery (LCA). Moreover, the LCA ostium itself was near the remote commissure in sinus 1, very far from the target re-implantation point. All of these conditions made LCA transfer very difficult. We used a coronary elongation technique to solve this problem. An inverted U-shaped flap was made in the wall of the neoaorta, and the LCA cuff was anastomosed to this flap (the inferior half from the neoaortic flap and the superior half from the LCA cuff). To prevent compression of the LCA, the neopulmonary trunk was shifted rightward. Postoperative echocardiography showed good left ventricular wall motion, and the LCA was easily visualized on chest computed tomography, with no compression from the neopulmonary artery.

Blood supply--susceptible formation of melanin pigment in hair bulb melanocytes of mice.

Background:Allogeneic skin grafts onto C57BL/6 mice are rejected, and the rejected skin is replaced by surrounding skin with black hair. In contrast, syngeneic skin grafts are tolerated, and gray hair grows on the grafts.Methods:To explore the mechanism of gray hair growing on the tolerated skin grafts, we prepared full-thickness skin (2-cm square) autografts, 2 (2 cm + 2 cm) horizontal or vertical parallel incisions, and U-shaped (2 cm × 2 cm × 2 cm) flaps with or without pedicle vessels. The grafts, incisions, and flaps were fixed by suturing with string and protected by a transparent bandage. On day 14 after the operation, the bandages were removed to observe the color of the hair growing on the skin.Results:Skin autografts from wild-type or hepatocyte growth factor-transgenic (Tg) C57BL/6 mice survived with gray hair, whereas those from steel factor (Kitl)-Tg C57BL/6 mice survived with black hair. In addition, U-shaped flaps lacking both of the 2 main feeding vessels of wild-type mice had gray hair at the tip of the flaps. Light microscopy after staining with hematoxylin and eosin or dihydroxyphenylalanine showed that the formation of melanin pigment in the follicles, but not in the interadnexal skin, was susceptible to the blood supply.Conclusions:Melanin pigment formation in the hair bulb melanocytes appeared to be susceptible to the blood supply, and melanocytosis was promoted in the follicles and in the epidermis of Kitl-Tg C57BL/6 mice.

Treatment of senile femoral neck fractures using bipolar hemiarthroplasty with enhanced repair of a U-shaped capsular flap via a modified posterior mini-incision

Objective To evaluate the efficacy of bipolar hemiarthroplasty with enhanced repair of a U-shaped capsular flap via a modified posterior mini-incision for senile femoral neck fractures. Methods Between June 2008 and June 2013, 86 senile patients with femoral neck fracture were treated operatively. They were 20 males and 66 females, 80 to 95 years of age (mean, 84.6 years). There were 70 cases of Garden type Ⅲ and 16 cases of Garden type Ⅳ. They all underwent bipolar hemiarthroplasty via a modified posterior mini-incision. A U-shaped posterior capsular flap with its base close to the acetabulum was made before exposure of the hip joint. Next this flap and short external rotators were repaired particularly after the bipolar prostheses were implanted. Incision length, surgical time, intra-operative loss of blood, and length of lower limb were measured. Malposition of prosthesis, hip dislocation and other complications were monitored. The outcomes were assessed according to Harris hip score at the last follow-up. Results The mean incision length was 9.2 cm (range, 8 to 12 cm). The mean surgical time was 75.2 min (range, 55 to 130 min). The mean intra-operative loss of blood was 250.1 mL (range, 120 to 620 mL). The proximal skin margin of the incision was bruised in 3 cases, deep venous thrombosis occurred at the lower limb 3 weeks postoperatively in one case, and length discrepancy between bilateral lower limbs was observed in 6 cases. No dislocation, incision infection, sciatic nerve injury, or component malpositioning happened in this group. All patients were evaluated after a mean follow-up period of 14 months (from 12 to 35 months). One patient died from lung cancer one year postoperatively. According to the Harris hip scores at the last follow-up, 68 cases were excellent, 15 good and 3 fair, giving an excellent to good rate of 96.5%. Conclusions The modified posterior mini-incision for localization of body surface is accurate, reliable and simple for senile femoral neck fractures. The bipolar hemiarthroplasty with enhanced repair of U-shaped capsular flap via this modified posterior mini-incision is in favor of early ambulation of the patients, and effective in reducing perioperative complications. Key words: Femoral neck fracture; Arthroplasty, replacement, hip; Surgical operation, minimally invasive; Surgical approach; Elderly people, aged 80 or over

Anti-inflammatory effects of Antrodia camphorata, a herbal medicine, in a mouse skin ischemia model

Ethnopharmacological evidenceAntrodia camphorata, a highly valued polypore mushroom native only to Taiwan, has been traditionally used as a medicine for anti-inflammation. Aim of the studyIn this study, anti-inflammatory effects of Antrodia camphorata (AC) and its active compound, ergostatrien-3β-ol (ST1), were investigated in a mouse skin ischemia model induced by skin flap surgery on the dorsal skin. Materials and methodsA U-shaped flap was elevated on the dorsal skin of the nine-week-old male mice. Mice were randomly assigned to six groups for treatment (n=6) including normal skin/propylene glycol (PG), surgical skin flap/PG, solid-state-cultured AC (S/AC), wood-cultured AC (W/AC), high-dose ST1 (H-ST1), low-dose ST1 (L-ST1). Antrodia camphorata was dissolved in 25μL PG and smeared on the skin flap every six hours for 24h. At the end of the experiment, each mouse was anesthetized, and skin tissues were collected from their back for histopathological analysis, extracting RNA and protein according to our previous reports. ResultsSkin-flap-induced ischemia damage significantly increased the expression of the iNOS, COX2, and IL-6 proteins and decreased the expression of IκB protein. In addition, focal, moderate coagulative necrosis with inflammatory cell infiltration was found in the epidermis, and moderate inflammatory cells and necrosis with slight edema was noted in the sub-dermis at 24h after skin flap surgery. However, treatment with solid-state-cultured or wood-cultured AC, or with its derived ST1 active compound, significantly reduced the necrosis and inflammatory cell infiltration in both the epidermis and sub-dermis of the skin flap. The treatments also reduced the inflammatory response by decreasing the expression of inflammation-related genes including iNOS, IL-6, TNF-α, and NF-κB, as shown by changes in RNA and protein expression, when compared with the surgical skin flap procedure alone. ConclusionsThese results demonstrated that methanolic extracts of wood-cultured fruiting bodies and solid-state-cultured mycelia from Antrodia camphorata have excellent anti-inflammatory activities and thus have great potential as an addition for hydrocolloid dressings.

In Reply

I thank the authors Giordano, Gravenstein, and Rice for their valuable comments on the subject of “Capnography Outside the Operating Rooms.”1 Due to the limitations of word count for “Clinical Concepts Commentary,” a detailed account of each capnogram was not provided. Given the wider scope of electronic accessibility, the intention of the article was to provide a comprehensive review of the use of capnography outside operating rooms not only to anesthesiologists and certified registered nurse anesthetists, but also to physicians in other specialties and nurses who provide sedation. Therefore, the article was scripted to provide a concise physiologic background and clinical applications of capnography.Giordano et al. raised important comments regarding capnograms 2C and 3A–D of the article.1 Analysis of capnograms 2C and 3A–D in the aforementioned article is a little more complex than the explanation provided by Giordano etal. Regarding 2C, they state that the inspiratory downstroke will sluggishly return to a zero baseline (or a β angle &gt;90 degrees) during inspiratory valve malfunction. This may be true in the typical circumstance described by Giordano et al., where an assumption is made that half of the expiratory gases will enter the inspiratory limb. However in reality, the quantity of expiratory gases entering the inspiratory limb is dependent on the resistance to the flow of expiratory gases in each limb of the circuit. The resistance in turn is dependent on the design of the valves, extent of malfunction of the inspiratory valve, fresh gas flows, and the length of the circuit. In addition, the carbon dioxide concentration across the inspiratory limb is also dependent on turbulent versus laminar flow of expiratory gases and mixing of carbon dioxide–free fresh gases with expiratory gases in the inspiratory limb (expiratory gases do not flow in blocks). For example, if malfunction of the inspiratory valve results in decreased resistance, it is conceivable that more than half of the expiratory gases might enter the inspiratory limb. This, in conjunction with the gas mixing between carbon dioxide–containing expiratory gases and carbon dioxide–free fresh gases may cause the final portion of the inspiratory tidal volume to contain certain amounts of carbon dioxide. Thus, the resulting downstroke of the capnogram (phase 0) will not reach the zero baseline. This was illustrated by me and my colleagues in a case report where we recorded capnograms during inspiratory valve malfunction and the subsequent inspiratory downstrokes did not reach the baseline.2 However, it was also demonstrated by our group that capnograms can apparently appear normal despite substantial rebreathing resulting from inspiratory valve malfunction. However, when respiratory gas flows were superimposed on the capnograms, the significant rebreathing was obvious.3Regarding capnogram 3A–D illustrated in the original article,1 the morphology of capnograms depends, once again, on several factors. These include patient’s respiratory rate, tidal volume, supplementary oxygen flow, gas leaks from the mask resulting in the carbon dioxide washout by the oxygen flow, and more importantly, the site of the carbon dioxide sampling. In capnograms 3A–D, the site of the sampling was adjacent to the inside wall of the mask via an adaptor, and not at the nostril. Therefore, the recorded carbon dioxide concentration does not represent the carbon dioxide concentration at the nostril. The morphology of the capnograms depends on the location of carbon dioxide sampling within the mask and on the washout of carbon dioxide by the supplementary oxygen flow. Unless carbon dioxide measurements are performed at the nostril, it may be difficult to ascertain whether there is rebreathing (although minimal). For example, figure 1A and B from this reply shows a patient undergoing upper gastroinstestinal endoscopy with supplementary oxygen provided via the mask, and end-tidal carbon dioxide monitoring was performed within the nostril using carbon dioxide sampling nasal cannula. The endoscope was inserted via a “U-shaped flap cut” in the mask. In this case, the carbon dioxide rebreathing was zero (fig. 1B) due to the carbon dioxide washout by supplementary oxygen at the nostril. Capnograms during sedation is a good subject for future discussion.

Lateral nailfold reconstruction with fingertip tongue-shaped flap and finger web reconstruction with U-shaped flap in syndactyly correction

Objective To investigate the efficacy of lateral nailfold reconstruction with fingertip tongueshaped flap and finger web reconstruction with U-shaped flap in syndactyly correction.Methods From January 2005 to August 2011,28 eases of congenital syndaetyly were treated.Zig-zag incisions were made on both the palmar and dorsal aspects of the fused fingers to separate the fingers.The lateral nailfold was reconstructed with fingertip tongue-shaped flap.Meanwhile,a U-shaped flap was designed between the dorsal metacarpophalangeal joints to form the finger web.The remainder of the lateral sides of the separated fingers was covered with fullthickness skin graft.Light compression dressing and postoperative prophylactie antibiotics were applied.Functional exercises were initiated upon suture removal.Results The finger web in all 28 cases was close to normal.Lateral nailfold reconstruction was satisfactory.There was no exposed distal phalanx.The appearance was good.Significant improvement was seen in finger flexion/extension and adduction/abduction.The overall results were satisfactory.Conclusion Lateral nailfold reconstruction with fingertip tongue-shaped flap and finger web reconstruction with U-shaped tlap is a good option in syndactyly correction.It leads to satisfactory restoration of both appearance and function. Key words: Surgical flaps; Hand deformities,congenital; Syndactyly

Tunica Albuginea Underlap—A New Modification of the Nesbit Procedure: Description of the Technique and Preliminary Results

We describe a new surgical technique for the treatment of penile curvature that combines features of the Nesbit procedure with features of tunical plication. U-shaped flaps of tunica albuginea are freed from the corpus cavernosum. The flaps are brought under the remaining tunica albuginea and are fixated with single absorbable sutures. As the defects of the tunica are sealed tightly and with high tensile strength by double layers of tunica albuginea, correction of the abnormal curvature is achieved. To present our experience with a new surgical technique for the treatment of penile curvature. Between 2008 and 2011, 50 patients underwent the underlap technique because of Peyronie's disease (37) or congenital penile deviation (13) in a single center. Preoperative and postoperative evaluation included the Erection Hardness Score (EHS) and the Symptom Score for Induratio penis plastica (IPP-SSC), a symptom score for penile deviation that was based on a consensus of regional andrologists. Clinical data concerning the early postoperative outcome were analyzed retrospectively using standardized items. Mean age ± standard deviation was 59.7 ± 8.4 years for patients with Peyronie's disease and 34.1 ± 7.8 years for patients with congenital penile deviation. The mean follow-up period was 27 months. The major complication rate was 4%, overall satisfaction 86%. Intraoperative correction of the curvature was achieved in 100%, significant relapse occurred in 6%. The mean difference of preoperative and postoperative IPP-SSC was 8.1 (95% confidence interval [CI] 7.24 to 8.96). The mean difference of preoperative and postoperative EHC was -0.03 (95% CI -0.16 to 0.09). Preliminary results obtained with the underlap technique showed promising outcome with minimal morbidity. The new technique might have three main advantages: more flexible intraoperative correctability of the curvature, tighter sealing of the tunical defects, and greater tensile strength of the plications.

The results of dismembered flap pyeloplasty for hydronephrosis in children

Aim. To evaluate the effectiveness of dismembered flap pyeloplasty for extensive obstruction of the pyeloureteral segment in children. Methods. Dismembered flap pyeloplasty throughout the period 2001-2010 was performed in 9 children (first group), mean age 69 months, 7 (77.8%) boys and 2 (22.2%) girls. Left-sided hydronephrosis was diagnosed in 8 (88.9%) cases, right-sided hydronephrosis - in 1 (11.1%) case. Dismembered flap pyeloplasty was performed in those cases, when after the resection of the ureter and during an attempt to form a direct uretero-pyelo-anastomosis excessive tension of the tissues occurred. In order to replace the resected part of the ureter used was a tubularized U-shaped flap of the renal pelvis, which was anastomosed in an «end to end» fashion with the proximal section of the ureter. The comparison group (second group, 58 patients) included patients who had undergone dismembered pyeloplasty with the formation of uretero-pyelo-anastomosis in the horizontal plane after standard resection of the dysplastic area of the proximal ureter. Results. In the early postoperative period, clinical manifestations of urinary tract infections were recorded in 1 (11.1%) of 9 patients, treated medically. The degree and rate of reduction of the increased anteroposterior size of the renal pelvis after dismembered flap pyeloplasty significantly lagged behind the comparable parameters of patients undergoing standard dismembered pyeloplasty, and at the same time, one year after the operation noted was a marked decrease in the anteroposterior size of the renal pelvis by almost 3 times as compared to the preoperative values. Conclusion. Implementation of dismembered flap pyeloplasty for extensive ureter obstruction makes it possible to achieve good short- and long-term results in the treatment of hydronephrosis in children.

Inverted U-Shaped Purse and Rotation Flaps: Correcting the Inferoposterior Deformity of Reconstructed Ears After Canaloplasty of the External Auditory Meatus

After patients with congenital microtia receive external ear canal plasty, the mastoid area usually has insufficient space for ear reconstruction. Hence, after ear reconstruction, an inferoposterior position deformity of the ear appears to some extent. Using inverted U-shaped purse and rotation flaps can correct this deformity effectively. From May of 2009 to September of 2011, five patients received the described procedures in the authors' department. Inverted U-shaped purse and rotation flaps were used for all the patients. The inverted U-shaped purse flap was used to reduce the area of the canal orifice and to lower the position, and the rotation flap was applied to turn the ear in a more superoposterior position. Two patients also received full-thickness skin grafting to cover the secondary wound. In four patients, V-Y-plasty or Z-plasty was used to adjust the flap transition. For the five patients, the distances between the ear antihelix and canal orifice were shortened, and the areas of the canal orifice were diminished. The retroversion of the auricle was corrected in various degrees, and the angles of the long axis of the auricle and the horizontal line were increased an average of 14.4°. The vertical distance between the top of the helix and the center of the canal orifice was increased an average of 15.2 mm. A slight dog ear deformity in front of the crus of the helix was left after the operation, but it was alleviated in the follow-up period. By using inverted U-shaped purse and rotation flaps, the inferoposterior position deformity of the reconstructed ear after external ear canal plasty in congenital microtia can be resolved effectively. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Reconstruction of the helical rim via postauricular U-shaped flap

Reconstruction of the helical rim via postauricular U-shaped flap

Protection of high-riding aberrant innominate artery during open tracheotomy

Variations of the normal anatomy of the aortic great vessels can lead to severe complications if not recognised pre- or peri-operatively. One such anomaly is a high-riding aberrant innominate artery. Retrospective review of case series. We present our experience with seven patients in whom a high aberrant innominate artery was encountered just before or during open tracheotomy. We describe a procedure designed to protect the artery from erosion due to the tracheotomy tube, using an inferiorly based, U-shaped flap from the anterior tracheal wall averted over the innominate artery. None of the patients had any bleeding from the tracheotomy site, during a follow-up period of nine to 46 months. The technique described is simple to perform and prevents any damage to a high aberrant innominate artery, as assessed over a long follow-up period.

Modified trans-oral approach with an inferiorly based flap

The trans-oral approach allows direct access to pathologies of the anterior craniocervical junction. However, the classic midline incision of the posterior pharyngeal wall can be surgically burdensome and limits lateral exposure. We reviewed the medical records of nine patients undergoing the trans-oral approach. The sites of the pathology ranged from the clivus to C2, and surgical exposure ranged from the clivus to C3. Each operation utilized an inferiorly based flap. None of the patients experienced vascular or neurologic complications, and no patient had a cerebrospinal fluid fistula, pseudomeningocele, or meningitis postoperatively. The trans-oral approach with an inferiorly based flap can therefore be safely and effectively performed with minimal oropharyngeal and neurologic morbidity. Not only does a U-shaped flap allow adequate exposure from the lower half of the clivus to C3, a flap improves lateral exposure, provides a clear operating field, and allows superficial mucosal closure not directly overlying the operative field.

Correction of incomplete cleft palate by u-shaped flap palatoplasty

During cleft palate repair, velopharyngeal sphincter reconstruction is still a challenge to plastic surgeons. To improve results of surgical treatment of cleft palate and secondary velopharyngeal incompetence, a carefully designed modified procedure for palatoplasty is presented. Thirty patients with incomplete cleft palate corrected by this procedure from April 2003 to October 2007 were included. A u-shaped incision was made in the anterior palate to separate bipedicle flap based on the greater palatine arteries of both sides. After complete dissection of the nasal and palatal mucosa, palatal muscles were carefully dissected from the posterior edge of the bones of the hard palate, wherein the well-mobilised flap receded backward spontaneously and elongated the soft palate. After suturing the nasal mucosa in the midline, the dissected palatal muscles of both sides were sutured together in the anterior third of the soft palate. On suturing the nasal mucosa and the palatal muscles, the soft palate became elongated and the oral mucosa was seen receding backward spontaneously to cover the anterior part of the soft palate. All corrected patients showed good results, with no recurrence, no post-operative fistulae, with accepted speech pattern and no need for further pharyngoplasty. The line of the sutured nasal mucosa and the palatal muscles became covered by the healthy non-sutured oral mucosa and the soft palate became elongated, with narrowing of the vellopharyngeal isthmus after this technique. The designed flap allows covering of sutured nasal mucosa and palatal muscles with a healthy unsutured oral mucosa and elongates the soft palate. Thus, there was no incidence of post-operative fistula and no need for further pharyngoplasties.