Flap vs flapless technique for impacted third molar removal: A split mouth prospective randomized control study

The aim of this study was to compare the post-operative sequelae of removal of impacted third molars in participants treated with conventional flap elevation technique or with a minimally invasive flapless technique. Participants with bilaterally impacted mandibular third molars were included. They were divided into two sites constituting 2 groups. One group was operated by using conventional flap design and elevation and other with flapless technique. Objective clinical parameters were recorded and compared in the post-operative period like mouth opening, swelling, surgical time, and pocket depth. Subjective parameters including pain were also assessed and statistically analyzed. The sites operated in Group II (Flapless technique) had better results (p≤0.05) in terms of pain, swelling, trismus, and pocket depth distal to second molar when compared to Group I (Flap). The flapless technique gives better surgical results and improved healing process after third molar removal and so should be recommended in routine clinical practice.

Flap vs flapless technique for impacted third molar removal: A split mouth prospective randomized control study

The aim of this study was to compare the post-operative sequelae of removal of impacted third molars in participants treated with conventional flap elevation technique or with a minimally invasive flapless technique. Participants with bilaterally impacted mandibular third molars were included. They were divided into two sites constituting 2 groups. One group was operated by using conventional flap design and elevation and other with flapless technique. Objective clinical parameters were recorded and compared in the post-operative period like mouth opening, swelling, surgical time, and pocket depth. Subjective parameters including pain were also assessed and statistically analyzed. The sites operated in Group II (Flapless technique) had better results (p≤0.05) in terms of pain, swelling, trismus, and pocket depth distal to second molar when compared to Group I (Flap). The flapless technique gives better surgical results and improved healing process after third molar removal and so should be recommended in routine clinical practice.

Comparative Analysis of Two Flap Designs for the Extraction of Impacted Mandibular Horizontal Third Molars: a Multicenter Randomized Control Trial

Most patients experience postoperative complications caused by the extraction of impacted mandibular horizontal third molars. The aim of the present study was to compare the effects of two flap designs as a refinement on the reduction of postoperative complications. One hundred eighty-eight patients with impacted mandibular horizontal third molars were included in this single-blind, multicenter, randomized control trial. The allocation was determined using a modified envelope flap (mEF) and triangular flap (TF) at 1:1 by the data manager. Postoperative complications (pain, hemorrhage, nerve paralysis, dry socket, and infection) and operation time were assessed 7 ± 1 days after surgery. In all cases, postoperative pain was significantly lower in the mEF group (P<0.05). In the subgroup analysis, postoperative pain was significantly lower in patients with low difficulty (IA, IIA, IIA, IB), which were classified by G.B. Winter classification (P<0.05). Other factors were not significantly associated with the flap design. Our study suggests that mEF resulted in less postoperative pain with a low difficulty of impacted mandibular horizontal third molars. However, the evidence at present is not sufficient to suggest the use of either flap design.

The importance of a lifeboat-median artery forearm flap in Goldenhar Syndrome

We present a case of a 32-year-old male with left-sided Goldenhar Syndrome and delta phalanx of the thumb, who was offered free tissue transfer from the forearm to address an intra-oral soft tissue deficiency. Despite the presence of appropriately developed right radial artery, used in previous facial reconstruction, the left radial artery occurred to be hypoplastic. He ultimately underwent free flap transfer based on the anomalous persistent left median artery. We suggest that in face of an unusual hand anatomy, flexible flap creation techniques that allow a lifeboat strategy of adjusting flap design should be considered preoperatively. Level of evidence: Level V, therapeutic study.

350 Cross Over Septal Flap Technique for Choanal Atresia Surgery: Two Centre Series with Outcomes

Introduction Choanal atresia (CA) is a congenital obstruction of the posterior nasal aperture due to nasal cavity canalisation failure. Endoscopic endonasal surgery has led to successful CA repair and fewer complications compared to open surgery. We describe our surgical technique that uses septal mucosal flaps without need for stenting or subsequent intubation. Method A multicentre retrospective review of patients who underwent surgery using the cross over septal technique. Patient demographics and outcomes were recorded. Flap design: bilateral vertical septal mucosa incisions are performed on either side of the posterior third of the septum to form two mucoperiosteal flaps. The posterior vomer and atretic plates are removed. One flap is pedicled superiorly and rotated over the bare sphenoid rostral bone. The contralateral flap is pedicled inferiorly and rotated to cover exposed bone of nasal cavity floor. Lateral nasal wall mucosal integrity is maintained. This technique is used both for unilateral and bilateral atresia. Results Twelve patients from 2013 to 2020 were included. Age range was 0.07-50 years, male to female ratio of 1:5. Ten patients had unilateral CA, two had bilateral. Nine had bony CA, the remainder mixed. 5 patients (mean age 2.8 years) underwent second-look endoscopy under sedation an average 36 days following primary surgery. Conclusions The cross over technique for CA has low morbidity and 100% success in our multicentre series. Use of mucoperiosteal flaps to cover the exposed bone, removal of vomer and minimal instrumentation to the lateral nasal wall are the best ways to avoid postoperative stenosis.

Autogenous mucochondral-osteal nasoseptal graft for reconstruction of orbital floor: a preliminary study

<p class="abstract">Resection of malignant sinonasal/skull base tumors that erode the orbital floor often result in large defects. We describe a technique for orbital floor reconstruction using a structural pedicled mucochondral-osteal nasoseptal flap (PMCONSF) that includes both soft tissue and bony-cartilaginous components with a continuous pedicled vascular supply. Case presentation was 11 patients having tumors associated with midface requiring maxillectomy and removal of inferior wall of orbit were included. Reconstruction of floor of orbit was done using PMCONSF. Post-operative outcomes of the techniques were studied. In all 11 cases reconstruction of floor of orbit was done using pedicled nasoseptal cartilage and in none of the cases communication of the orbital content with maxillary sinus was encountered. Complete ophthalmic examination revealed no significant diplopia, no entrapment of ocular structures with good ocular motility. Adequate reconstruction of the orbital floor is crucial to maintaining long-term ocular function. The PMCONSF offers great flexibility in flap design as well as a high rate of success. The bony-cartilaginous component offers a rigid structural part to the orbital floor, eliminating the functional defects that can occur from anatomical changes. The pedicled vascular supply helps assist in graft integration, limiting the potential for graft rejection or necrosis following postoperative radiotherapy. We believe that this graft offers a viable alternative to existing methods for orbital reconstruction in patients with large orbital floor defects, especially for cases in which adjuvant postoperative radiotherapy is anticipated.</p>

Use of the Vertical Profunda Artery Perforator Flap to Capture the Dominant Perforator: A Cadaver Dissection and Imaging Study

Introduction While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant. Methods Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators. Results In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF. Conclusion The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.

Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

Background Distal lower extremity reconstruction can be challenging in terms of flap design. Bulky flaps result in limited mobility accompanied with the need of customized footwear. Raising the ALT-flap in a superficial fascial plane (thin ALT-flap) can be beneficial. This study evaluates thin ALT-flaps for lower distal extremity reconstruction. Methods In a retrospective study, patients that underwent microvascular extremity reconstruction at the level of the ankle and dorsal foot at the University of Freiburg from 2008–2018 were reviewed. Results 95 patients could be included in the study (35 perforator flaps, 8 fascia flaps and 54 muscle flaps).Among the perforator flaps, 21 ALT-flaps were elevated conventionally and 14 in the superficial fascial plane (thin ALT-flap). Among the conventional ALT-flaps, there was one flap loss (5%) and one successful revision (5%). 5(24%) flaps received secondary thinning. 57%(n = 12) were able to wear conventional footwear. There were 2(15%) successful revisions of thin ALT-flaps. 100% of thin ALT-flaps survived and 85%(n = 11) of the patients wore ordinary footwear after defect coverage.Among fascial flaps, 50%(n = 4) had to be revised with 2(25%) complete and 1 (13%) partial flap loss. All patients achieved mobility in ordinary shoes (n = 8).In muscle flaps, there were 7(13%) revisions and 5(9%) flap losses. 5(9%) flaps received secondary thinning. Only 33%(n = 18) were mobile in ordinary footwear. Conclusion The thin ALT-flap is a save one-stage evolution for lower distal extremity reconstruction with a favorable flap survival rate. Compared with conventional ALT-flaps it might be beneficial in reducing the need for expensive custom fitted shoes and secondary thinning procedures.