Reconstruction of a large lower lip defect using a combination of Abbe and staircase flaps: a case report

Lip defects often occur following wide excision as a surgical treatment for squamous cell carcinoma of the oral cavity. Defects larger than one-half of the lip cannot be closed primarily and require flap surgery. Reconstruction of the oral sphincter function can be achieved by means of a local flap using the like tissue, rather than with a free flap utilizing different tissues. A defect of the lower lip requires reconstruction using different techniques, depending on its size and location. Herein, we present the case of a patient exhibiting a lip defect spanning more than two-thirds of the lower lip, after a wide resection due to squamous cell carcinoma. The defect was reconstructed using an Abbe flap and a staircase flap. Revision was performed after 16 days. The patient’s oral competencies were fully restored 3 months postoperatively, and the esthetic results were ideal. Based on our experience, a combination of the Abbe and staircase flaps can produce excellent functional and esthetic outcomes in the reconstruction of a lower lip with a large defect. It can serve as a reliable reconstruction option for defects spanning more than two-thirds of the lower lip, not including the oral commissures.

Remained Large Bone Fragment of Bony Bankart Lesion in Shoulders With a Subcritical Glenoid Defect at Recurrent Anterior Instability

Background: A preoperative glenoid defect of 13.5% or larger is recognized as a subcritical glenoid defect at arthroscopic Bankart repair (ABR) for collision/contact athletes or military personnel. Purpose: To clarify the prevalence and size of remaining bone fragments in shoulders with a subcritical glenoid defect at recurrent anterior instability and to investigate the influence on postoperative recurrence after ABR for younger competitive athletes. Study Design: Cohort study; Level of evidence, 4. Methods: The study included 96 shoulders with recurrent instability that underwent ABR between July 2011 and March 2018 for shoulders with a subcritical glenoid defect. The patients were divided into 2 groups according to the glenoid defect size (13.5%-<20%, medium; ≥20%, large). The bone fragment size in each defect group was retrospectively investigated and classified into 4 groups (no, 0%; small, >0%-<5%; medium, 5%-<10%; large, ≥10%). The postoperative recurrence rate for each combination of glenoid defect size and bone fragment size was investigated for competitive athletes aged <30 years. The fragments, when present, were repaired to the glenoid. Results: The glenoid defect size was 13.5%-<20% in 60 shoulders (medium defect group) and ≥20% in 36 shoulders (large defect group). The mean bone fragment size was 6.7% ± 5.1% and 8.9% ± 4.9%, respectively ( P = .042). In the medium defect group, there were 15 shoulders (25%) without a bone fragment, 6 shoulders (10%) with a small fragment, 23 shoulders (38.3%) with a medium fragment, and 16 shoulders (26.7%) with a large fragment. In the large defect group, the respective numbers were 2 shoulders (5.6%), 6 shoulders (16.7%), 14 shoulders (38.9%), and 14 shoulders (38.9%). A medium or large bone fragment was more common in the large defect group ( P = .252). Among 64 younger competitive athletes who underwent ABR with a minimum of 2 years of follow-up, postoperative recurrence was recognized in 7 of 38 (18.4%) athletes in the medium defect group, but it was not recognized in any of the 26 athletes in the large defect group ( P = .036). Postoperative recurrence was recognized in 4 of 12 (33.3%) athletes with a small fragment or no fragment and in 3 of 52 (5.8%) athletes with a medium or large fragment ( P = .019). Conclusion: A larger bone fragment frequently remained in shoulders with a subcritical glenoid defect at recurrent instability. The postoperative recurrence rate after ABR for younger competitive athletes was low when a remaining larger bone fragment was repaired.

Karapandzic Flap for Functional & Cosmetic Reconstruction of Lower Lip Cancer with Review of Literature

The incidence and prevalence of lip and oral cavity cancer has increased over the last decade, worldwide and in India. It ranks at 1st position in males in india, all ages, in 2020. Lips are essential organ of the body which carries dynamic role in facial expression, speech, sensuality, deglutition. Resection of central, large, lower lip cancer creates a more than 2/3rd large defect. Covering of this defect with maintenance of oral competency is a difficult task for a treating surgeon. Number of techniques are described for covering of large lower lip defects. Out of these techniques, karapandzic flap is a successful, accepted, simple, easy to learn reconstructive procedure with good cosmetic results. It is a modification of Gillie’s fan flap and it involves unilateral or bilateral full-thickness circumoral advancement-rotation flaps. The feature which distinguishes it from other techniques is preservation of neuro-vascular integrity, symmetry and oral competency. We are reporting a case of an elderly gentleman with large, central, lower lip cancer who underwent oncological resection with reconstruction by karapandzic flap technique.

Esthetic and functional reconstruction of large mandibular defects using free fibula flap and implant-retained prosthetics - a case series with long-term follow-up

Background The reconstructive and rehabilitative management of large mandibular defects with basal continuity is challenging in many respects, especially in the vertical dimension. The free fibula flap is an under-utilised but efficient approach in this indication. The aim of this case series is to demonstrate its use and long-term success. Case presentation Three cases are presented, where the patient had a large bone defect (at least 5 cm in length and 1 cm in the vertical dimension), but the continuity of the mandible was maintained. Two cases were related to pathological fracture and one was a large defect due to oncological surgery. Vertical augmentation with free microvascularised fibula flap was carried out, followed by implant-retained prosthetic therapy. Clinical status has been followed up for 5 to 6 years, with special attention to the condition of the peri-implant tissues and any radiographically detectable alterations or complications. No complications occurred during the follow-up. Function and esthetics have remained unchanged throughout. Conclusions Free microvascularised fibula flap reconstruction combined with implant-retained prosthetics allows a lasting functional and esthetic solution in the discussed indication.

Umbilical hernia repair and recurrence: need for a clinical trial?

Introduction Umbilical hernia repair, despite its perceived simplicity, is associated with recurrence between 2.7 and 27%, in mesh repair and non mesh repair respectively. Many factors are recognized contributors to recurrence however multiple defects in the linea alba, known to occur in up to 30% of patients, appear to have been overlooked by surgeons. Aims This systematic review assessed reporting of second or multiple linea alba defects in patients undergoing umbilical hernia repair to establish if these anatomical variations could contribute to recurrence along with other potential factors. Methods A systematic review of all published English language articles was undertaken using databases PubMed, Embase, Web of Science and Cochrane Library from January 2014 to 2019. The search terms ‘Umbilical hernia’ AND ‘repair’ AND ‘recurrence’ were used across all databases. Analysis was specified in advance to avoid selection bias, was registered with PROSPERO (154173) and adhered to PRISMA statement. Results Six hundred and forty-six initial papers were refined to 10 following article review and grading. The presence of multiple linea alba defects as a contributor to recurrence was not reported in the literature. One paper mentioned the exclusion of six participants from their study due multiple defects. In all 11 factors were significantly associated with umbilical hernia recurrence. These included: large defect, primary closure without mesh, high BMI in 5/10 publications; smoking, diabetes mellitus, surgical site Infection (SSI) and concurrent hernia in 3/10. In addition, the type of mesh, advanced age, liver disease and non-closure of the defect were identified in individual papers. Conclusion This study identified many factors already known to contribute to umbilical hernia recurrence in adults, but the existence of multiple defects in the linea, despite it prevalence, has evaded investigators. Surgeons need to be consider documentation of this potential confounder which may contribute to recurrence.

Closure of large lumbosacral defect using a combined method of bilateral bipedicle flap with lateral releasing incision and Integra® dermal regeneration template

BACKGROUND: Myelomeningocele is one of the most complex congenital malformations of the central nervous system. It is one of the most common types of spina bifida which involves a failure of neural tube closure. Reconstruction surgery for myelomeningocele had always been challenging for plastic and neurosurgeons. CLINICAL CASE: We report a case of a new-born with lumbosacral myelomeningocele who received treatment in the Hospital Universiti Sains Malaysia. The myelomeningocele was repaired by the neurosurgery team and subsequently, the child was left with huge lumbosacral skin defect. The large defect was successfully covered by using a combined method of bilateral bipedicle flap with lateral releasing incision and remaining lumbosacral and secondary defect resurfaced using Integra dermal regeneration template (DRT). We used ACTICOAT interfaced negative pressure wound therapy (NPWT) as our main dressing in preparing the wound bed for autologous epidermal graft. The result of our closure technique provides tension free closure. DISCUSSION: We incorporated bilateral bipedicle fasciocutaneous flap technique together with DRT for closure of the lumbosacral defect. The bilateral bipedicle flap with lateral releasing incision served to reduce tension on the skin at bilateral lumbar region. The DRT downsized the lumbosacral defect and NPWT dressing provided an optimal sterile environment in giving time for neodermis generation. The remaining secondary defect were also resurfaced utilizing DRT and autologous skin grafting. CONCLUSIONS: The outcome of surgery demonstrated that the combined use of bilateral bipedicle fasciocutaneous flap with lateral releasing incision and DRT with delayed skin grafting is safe, effective and provide long term stable and supple scar for large, exposed dura defect.

High Maternal Neonatal Mortality and Morbidity in Pregnancy with Eisenmenger Syndrome

Objectives. This study is aimed at evaluating the maternal and perinatal characteristics and pregnancy outcomes of ES. Material and Methods. This is a retrospective cohort study of pregnancy with Eisenmenger syndrome (ES) in Dr. Soetomo Hospital from January 2018 to December 2019. Total sampling size was obtained. We collected all baseline maternal-perinatal characteristic data, cardiac status, and pregnancy outcomes as primary outcomes. The maternal death cases were also evaluated, and we compared characteristics based on defect size (< or >3 cm). Results. During study periods, we collected 18 cases with ES from a total of 152 pregnancies with heart disease. The underlying heart disease type includes atrial septal defect (ASD), ventricle septal defect (VSD), and patent ductus arteriosus (PDA). All cases suffered pulmonary hypertension (PH), 3 cases moderate, and 15 cases as severe. 94% of cases fall into heart failure (DC FC NYHA III-IV) during treatment. The majority of cases are delivered by cesarean section (88.9%). Pregnancy complications found include preterm birth (78%), low birthweight (94%), intrauterine growth restriction (55%), oligohydramnios (16%), severe preeclampsia (33%), and placenta previa (5.5%). Large defect group has an older maternal ages ( 30.18 ± 4.60 vs. 24.15 ± 2.75 ; p = 0.002 ), higher clinical sign (100 vs. 40%, p = 0.003 ), and higher preterm delivery rate (100% vs. 69%, p = 0.047 ) compared to small defect groups. The R to L or bidirectional shunt is significantly higher at the large defect group (13 vs. 5 cases, p = 0.006 , 95% confidence interval: -1.156 to -0.228). There were seven maternal death cases caused by shock cardiogenic. Conclusions. Pregnancy with ES is still associated with very high maternal neonatal mortality and morbidity. The larger defect size is correlated with clinical performances and pregnancy outcomes. Effective preconception counseling is the best strategy to reduce the risk of maternal and neonatal death in ES women.