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Tanner, Cary, Toby Johnson, Alex Majors, et al. "The Vascularity and Osteogenesis of a Vascularized Flap for the Treatment of Scaphoid Nonunion: The Pedicle Volar Distal Radial Periosteal Flap." HAND 14, no. 4 (2018): 500–507. http://dx.doi.org/10.1177/1558944717751191.
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Background: Vascularized periosteal flaps from the distal radius have been previously proposed. The purpose of this study was to investigate the vascularity and osteogenic potential of a vascularized volar distal radial periosteal flap for the treatment of scaphoid nonunion. Methods: In 5 fresh frozen cadavers, a rectangular periosteal flap was elevated from the distal radius with the pedicle just proximal to the watershed line. Latex dye was injected into the radial artery proximally and the vascularity of the flap characterized by microscopic evaluation. Patients with scaphoid nonunion were then treated with open reduction, internal fixation, and distal radius cancellous bone graft. Two groups of patients with midwaist nonunion scaphoid were then evaluated. The first group received the vascularized periosteal flap and the second group received a nonvascularized periosteal flap. A third group of proximal pole nonunions also received the vascularized flap. Results: Cadaveric dissections revealed that all of the injected flaps demonstrated vascularity to the distal edge of the flap. Vascularized flaps formed visible bone on imaging in 55% of cases. None of the nonvascularized flaps formed visible bone. In group 1, 12/12 midwaist nonunions united. In group 2, union was achieved in 6/6 of patients who completed the follow-up. In group 3, 6/7 proximal pole fractures united. Conclusions: Previously proposed vascularized periosteal flaps from the distal radius appear to possess notable osteogenic potential that may be of interest to surgeons treating scaphoid nonunion.
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Scampa, Matteo, Vladimir Mégevand, Jérôme Martineau, Dirk J. Schaefer, Daniel F. Kalbermatten, and Carlo M. Oranges. "Medial Femoral Condyle Free Flap: A Systematic Review and Proportional Meta-analysis of Applications and Surgical Outcomes." Plastic and Reconstructive Surgery - Global Open 12, no. 4 (2024): e5708. http://dx.doi.org/10.1097/gox.0000000000005708.
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Background: Recalcitrant bone nonunion and osseous defect treatment is challenging and often requires vascularized bone transfer. The medial femoral condyle flap has become an increasingly popular option for reconstruction. The study aims at reviewing its different applications and synthesizing its surgical outcomes. Method: A systematic review including all studies assessing surgical outcomes of free medial femoral condyle flap for bone reconstruction in adults was conducted on January 31, 2023. Flap failure and postoperative complications were synthesized with a proportional meta-analysis. Results: Forty articles describing bony reconstruction in the head and neck, upper limb, and lower limb areas were selected. Indications ranged from bony nonunion and bone defects to avascular bone necrosis. Multiple flaps were raised as either pure periosteal, cortico-periosteal, cortico-cancellous-periosteal, or cortico-chondro-periosteal. A minority of composite flaps were reported. Overall failure rate was 1% [95% confidence interval (CI), 0.00–0.08] in head & neck applications, 4% in the lower limb (95% CI, 0.00–0.16), 2% in the upper limb (95% CI, 0.00–0.06), and 1% in articles analyzing various locations simultaneously (95% CI, 0.00–0.04). Overall donor site complication rate was 4% (95% CI, 0.01–0.06). Major reported complications were: femoral fractures (n = 3), superficial femoral artery injury (n = 1), medial collateral ligament injury (n = 1), and septic shock due to pace-maker colonization (n = 1). Conclusion: The medial femoral condyle flap is a versatile option for bone reconstruction with high success rates and low donor site morbidity.
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Bartholomew, Ryan, Joseph Zenga, Derrick Lin, Daniel Deschler, and Jeremy Richmon. "Tip-on-Tip Scapular (TOTS) Flap for Reconstruction of Combined Palatectomy and Rhinectomy Defects." Facial Plastic Surgery 34, no. 04 (2018): 389–93. http://dx.doi.org/10.1055/s-0038-1666784.
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AbstractCombination anterior palatectomy and rhinectomy defects result in complete loss of midface and nasal support and present a significant reconstructive challenge. A novel use of the scapular tip free flap—the tip-on-tip scapula flap—was developed to provide both palatal repair and restoration of intrinsic nasal support. The scapular tip bone is split into a large proximal segment for the anterior palate and a smaller distal bone segment for nasal framework reconstruction. Two patients undergoing reconstruction of both total palatectomy and partial rhinectomy defects at a single academic tertiary care center were reviewed. In both cases, the larger proximal segment of the scapular tip flap, used for the palatal defect, was based on the angular artery. The distal bone segment, used for nasal framework repair, was vascularized in one of two ways. In the osteomyogenous serratus-scapular tip variant, the serratus arterial branch provided periosteal blood supply to the bone through a cuff of attached serratus muscle. In the split-scapular tip variant, the periosteum of the scapular tip was kept in continuity with the distal bone segment and fed through the periosteal vascular arcade from the angular branch. In both patients, the distal bone segment demonstrated robust intraoperative vascularity and both flaps healed without complication. Both patients were able to resume oral diets and had good nasal breathing.
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Sanjay, Kumar, and Kumar Prakash. "Reverse Sural Flap for Regeneration of the Soft Tissues in the Ankle and Heel." International Journal of Pharmaceutical and Clinical Research 15, no. 7 (2023): 465–69. https://doi.org/10.5281/zenodo.11642268.
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<strong>Introduction:</strong> It has never been easy to restore large soft tissue lesions in the ankle and foot. There has been varying success using reverse sural flaps and free flaps for this issue. Without microvascular repair, the reverse peroneal artery flap is an alternative that can be used reliably. Anterior and posterior tibial arteries form deep and reliable connections with the peroneal artery around the talus and ankle joint. When the short saphenous vein and the reverse sural artery were included into the flap, arterial input and venous drainage improved. <strong>Materials and Method:</strong> Over the course of two years, ten patients with significant heel deformities underwent repair with a reverse peroneal artery flap (pedicled). Final inset given after initial surgery has healed after 18–21 days. These patients were 45 years old on average. <strong>Results:</strong> All ten flaps displayed full survival, with no signs of even minor necrosis. Two patients reported minor donor site issues that were treated conservatively and resolved. <strong>Conclusions</strong><strong>: </strong>For the purpose of covering significant soft tissue deformities of the heel and sole, RPAF is a very dependable flap. Without vascular microsurgery and without endangering the major vessels in the foot region, large abnormalities can be repaired. If there is prior knowledge of flapping perforators and a free fibula, RPAF is simple to do reliably.
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Singh, Vivian, and Marcus Atlas. "Obliteration of the Persistently Discharging Mastoid Cavity using the Middle Temporal Artery Flap." Otolaryngology–Head and Neck Surgery 137, no. 3 (2007): 433–38. http://dx.doi.org/10.1016/j.otohns.2007.02.034.
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OBJECTIVE: To evaluate the surgical outcome of patients undergoing obliteration of a persistently discharging mastoid cavity with specific soft tissue vascular flaps for chronic otitis media or cholesteatoma. STUDY DESIGN: A five-year retrospective consecutive case review in a tertiary care referral center. Following mastoidectomy obliteration with a superiorly based middle temporal artery, axial periosteal flap and inferiorly based random pedicled musculoperi-osteal flap was performed. The primary outcome was control of suppuration and the creation of a dry, low-maintenance cavity as assessed by a semi-quantitative scale. RESULTS: A total of 51 consecutive patients undergoing revision mastoidectomy with obliteration were identified with a minimum follow-up of 12 months; 43 (84%) had a small dry healthy mastoid cavity; three ears (6%) had occasional otorrhea that was relatively easily managed by topical therapy. CONCLUSION: Obliteration using the middle temporal artery and inferior random flaps is an effective method to manage patients with pre-existing cavities and also those not previously operated upon.
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Manojlovic, Radovan, Milan Milisavljevic, Dejan Tabakovic, Mila Cetkovic, and Marko Bumbasirevic. "Angiosome of the fibular artery as anatomic basis for free composite fibular flap." Srpski arhiv za celokupno lekarstvo 135, no. 3-4 (2007): 174–78. http://dx.doi.org/10.2298/sarh0704174m.
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Introduction. The free osteoseptocutaneus fibular flap is, anatomically, an angiosome of the fibular artery. Knowledge of detailed topography anatomy of the fibular artery and its branches is necessary for successful creation and elevation of the flap. Objective. The aim of the study was to determine topography of the tissue of the leg supplied only by the fibular artery, to describe topography relations of the branches of the fibular artery, their number, anastomoses, vascular plexus and the way of vascularization of the skin, muscle and bone tissue. Method. The popliteal artery was cannulated in 15 cadaveric legs, flushed with ink and then with 10% ink-gelatin. Fixation of tissue was performed with formalin and then micropreparation of the side branches of the fibular artery was performed. Also, two corrosive models were made. Localization of foramen nutrition was determined by measuring 50 fibulas. Results. The skin supplied by the fibular artery forms distal two thirds of the lateral-posterior aspect of the leg. Vascularization of the skin arises from the side branches of the fibular artery forming a rich fascia plexus at the deep fascia level. From 3 up to 7 side branches of the fibular artery are incorporated in the fascia arterial plexus and can be separated as septocutaneus and myocutaneus, according to topography relations. The nutritive artery enters the fibula cortex at a spot that, measured from the top of the fibula, lies in the area between 32% and 65% of the whole length of the fibula. Periosteal circulation of the fibula originates from the short side branches of the fibular artery that anastomoses at the periosteum level. Conclusion. The axial line of flap has to be marked 2 cm posterior to the line from caput fibulae to malleolus lateralis. Numerous anastomoses between the side branches of the fibular artery in the fascia plexus enable good circulation of the skin even when some of the branches are not included in the flap. The middle third of fibula has to be used as bone graft because of localization of the foramen nutrition. .
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FARRIOR, JAY B. "Postauricular Myocutaneous Flap in Otologic Surgery." Otolaryngology–Head and Neck Surgery 118, no. 6 (1998): 743–46. http://dx.doi.org/10.1016/s0194-5998(98)70262-1.
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Management of a large mastoid defect resulting from skull base operations or extensive surgical procedures because of chronic ear disease continues to challenge the otologic surgeon. Various local muscle or periosteal rotation flaps have been used to help reduce the size of the postoperative mastoid cavity. With these techniques there are problems with flap retraction and epithelization that may result in delayed healing or chronic drainage. Closure of the ear canal and tissue obliteration of the mastoid results in a maximal conductive hearing loss. A postauricular myocutaneous flap based on the occipital artery and sternocleidomastoid muscle has been used effectively to reconstruct mastoid defects after both surgical procedures for chronic ear disease and skull base operations. The skin muscle flap reduces the mastoid cavity and promotes rapid healing of the surgical defect. Although postauricular myocutaneous flaps have been found to be reliable, their viability may be compromised by arterial embolization used in larger glomus tumors. Indications for and creation of a postauricular myocutaneous flap, with results in 18 cases, are presented. (Otolaryngol Head Neck Surg 1998;118:743-6.)
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Knitschke, Michael, Anna Katrin Baumgart, Christina Bäcker, et al. "Computed Tomography Angiography (CTA) before Reconstructive Jaw Surgery Using Fibula Free Flap: Retrospective Analysis of Vascular Architecture." Diagnostics 11, no. 10 (2021): 1865. http://dx.doi.org/10.3390/diagnostics11101865.
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Computed tomography angiography (CTA) is widely used in preoperative evaluation of the lower limbs’ vascular system for virtual surgical planning (VSP) of fibula free flap (FFF) for jaw reconstruction. The present retrospective clinical study analysed n = 72 computed tomography angiographies (CTA) of lower limbs for virtual surgical planning (VSP) for jaw reconstruction. The purpose of the investigation was to evaluate the morphology of the fibular bone and its vascular supply in CTA imaging, and further, the amount and distribution of periosteal branches (PB) and septo-cutaneous perforators (SCPs) of the fibular artery. A total of 144 lower limbs was assessed (mean age: 58.5 ± 15.3 years; 28 females, 38.9%; 44 males, 61.1%). The vascular system was categorized as regular (type I-A to II-C) in 140 cases (97.2%) regarding the classification by Kim. Absent anterior tibial artery (type III-A, n = 2) and posterior tibial artery (type III-B, n = 2) were detected in the left leg. Stenoses were observed mostly in the fibular artery (n = 11), once in the anterior tibial artery, and twice in the posterior tibial artery. In total, n = 361 periosteal branches (PBs) and n = 231 septo-cutaneous perforators (SCPs) were recorded. While a distribution pattern for PBs was separated into two clusters, a more tripartite distribution pattern for SCPs was found. We conclude that conventional CTA for VSP of free fibula flap (FFF) is capable of imaging and distinguishing SCPs and PBs.
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Jacob, V., N. J. Mokal, and S. N. Deshpande. "Bi-lamellar lower eyelid reconstruction with superficial temporal artery island flap and hard palate muco-periosteal free graft." Indian Journal of Plastic Surgery 38, no. 02 (2005): 105–9. http://dx.doi.org/10.1055/s-0039-1699115.
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ABSTRACTThree cases of single stage, bi-lamellar reconstruction of full-thickness, horizontal, lateral three-quarter lower eyelid defects using pedicled island flaps of adjacent vascular territories and hard palate muco-periosteal graft are being presented. All cases were done for Basal Cell Carcinoma of the region. While the island flaps allowed for a simple, single stage reconstruction of the external lamella, the hard palate muco-periosteal graft, by virtue of its inherent resilience and a rich glandular component, took well and provided for a good functional and aesthetic result.The follow-up ranged from 6 to 40 months and the final result has been oncologically, functionally and aesthetically satisfactory.
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Talmage, Garrick D., Jumin Sunde, David D. Walker, Marcus D. Atlas, and Michael B. Gluth. "Anatomic basis of the middle temporal artery periosteal rotational flap in otologic surgery." Laryngoscope 126, no. 6 (2015): 1426–32. http://dx.doi.org/10.1002/lary.25635.
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Kuehnel, Sophia, András Grimm, Christopher Bohr, et al. "Reconstruction of the Exenterated Orbit with an Island Pericranial Flap: A New Surgical Approach." Plastic and Reconstructive Surgery - Global Open 11, no. 7 (2023): e5082. http://dx.doi.org/10.1097/gox.0000000000005082.
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Background: Reconstruction of the bony socket after orbital exenteration is a matter of much debate. Prompt defect closure with a microvascular flap is desirable but involves a major surgical procedure and hence, places considerable burden on the patient. The new surgical technique presented here permits a technically simpler wound closure with fewer complications after orbital exenteration. Methods: Between May 2014 and June 2022 in the ENT department of Regensburg University, nine patients underwent exenteration and reconstruction with a pericranial flap. The flap was raised via a broken line incision in the forehead or endoscopically, incised in a roughly croissant-like shape, then introduced into the orbit through a tunnel in the eyebrow. A retrospective analysis of the patients and considerations about determining the size, shape, and vascular supply of the flap are presented. Results: Flap healing was uncomplicated in all cases. Only 6 weeks after surgery, the flap was stable, making it possible to start adjuvant therapy and prosthetic rehabilitation swiftly. The flap is adapted to the near cone-shape of the orbit. The mean (± standard deviation) surface area of the measured orbits is (39.58 ± 3.32) cm2. The territory of the angular artery provides the periosteal flap arterial blood supply. Venous drainage is via venous networks surrounding the artery. Conclusions: Use of the pericranial flap makes it possible to close the orbital cavity promptly with minimal donor site defect and a short operating time, thereby minimizing the surgical risk and speeding up physical and psychological recovery.
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Yu, Jason W., Jordan D. Frey, Vishal D. Thanik, Eduardo D. Rodriguez, and Jamie P. Levine. "The Rich Get Richer: Osseous Chimeric Versatility to the Anterolateral Thigh Flap." Journal of Reconstructive Microsurgery 36, no. 03 (2019): 171–76. http://dx.doi.org/10.1055/s-0039-1698747.
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Abstract Background The lateral femoral circumflex artery (LFCA) system, which supplies the anterolateral thigh (ALT) flap territory, offers a plethora of tissue types for composite, functional reconstruction. However, the ability to include a reliable and flexible osseous component is limited. Based on cadaveric dissections, we describe an isolated LFCA branch to the femur separate from the vastus intermedius that can be included in ALT flap harvest in cases requiring bony reconstruction. Methods Cadaveric dissection was undertaken to define the LFCA vascular system with specific dissection of the proximal branches of the descending branch of the LFCA (db-LFCA) to define any muscular, periosteal, and/or osseous branches to the femur. Results Six thighs in four cadavers were dissected. Consistent in all specimens, there was an isolated branch extending distally, medially, and posteriorly from the proximal LFCA and entering the periosteum of the femur. In five specimens, the identified branch to the femur was located approximately 1-cm distal to the rectus femoris branch of the LFCA and approximately 1-cm proximal to a separate branch entering and supplying the vastus intermedius. In one specimen, there was a common trunk. The length of this branch from the origin at the LFCA to insertion into the femoral periosteum was approximately 6 to 8 cm. Conclusion There appears to be a consistent and reliable branch to the femur based on the proximal LFCA that may be included in ALT flap harvest, adding even more versatility, as another option in complex cases requiring composite reconstruction, including bone.
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Henry, Mark. "GENICULAR CORTICOPERIOSTEAL FLAP SALVAGE OF RESISTANT ATROPHIC NON-UNION OF THE DISTAL RADIUS METAPHYSIS." Hand Surgery 12, no. 03 (2007): 211–15. http://dx.doi.org/10.1142/s0218810407003651.
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Non-union at the metaphyseal level is rare following a fracture of the distal radius. When a non-union does occur, it is usually easily treated with cancellous bone graft from the iliac crest. Resistant and multiply operated atrophic non-unions more frequently occur at the diaphyseal level of long bones. A corticoperiosteal free flap based on the articular branch of the descending genicular artery has previously been described to treat such difficult non-union cases in various sites, but not at the distal radius. At the distal radius metaphysis, the close relationship with the extensor tendons raises concern regarding the ability to fit this free flap to the non-union site without significant interference with tendon function. By careful technique of crumbling the cortex of the flap without tearing the periosteal continuity, the flap can be contoured and snugly fit to this particular site while preserving tendon function. A unique case is presented of a multiply operated resistant atrophic non-union of the distal radius metaphysis in a heavy smoker that was rapidly healed using the genicular corticoperiosteal free flap.
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Jacob, V., NJ Mokal, and SN Deshpande. "Bi-lamellar lower eyelid reconstruction with superficial temporal artery island flap and hard palate muco-periosteal free graft." Indian Journal of Plastic Surgery 38, no. 2 (2005): 105. http://dx.doi.org/10.4103/0970-0358.19776.
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di Summa, P. G., G. Sapino, G. C. Higgins, and D. Guillier. "Freestyle superficial femoral artery perforator (SFAp) free flap combined with a free periosteal medial condyle flap in Gustillo IIb fracture: Overkill or ideal treatment?" Journal of Plastic, Reconstructive & Aesthetic Surgery 73, no. 7 (2020): 1253–54. http://dx.doi.org/10.1016/j.bjps.2020.02.047.
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Umnikov, A. S., M. N. Velichko, S. V. Tereshchuk, and D. A. Grechukhin. "A Method of Treating Scaphoid Nonunion by Applying Periosteal Flaps on Metacarpal Arteries." A.I. Burnasyan Federal Medical Biophysical Center Clinical Bulletin, no. 1 (April 2024): 36–43. http://dx.doi.org/10.33266/2782-6430-2024-1-36-43.
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The purpose of the study: to improve the method of surgical treatment of patients with scaphoid nonunion. Material and methods: the results of treatment of 30 patients operated on for scaphoid nonunion of the hand, which arose after conservative treatment (not treatment) of fractures, surgical treatment for 2018-2021 were analyzed. The patients were divided into two groups: 15 patients with scaphoid nonunion who underwent free bone autoplasty as a surgical aid, fixation of bone fragments with a headless screw – a control group; 15 patients with fscaphoid nonunion, who underwent free bone autoplasty as surgical treatment, supplemented with non-free plastic surgery with a periosteal flap on the metacarpal artery – the main (experimental) group of patients. The possibility of using periosteal flaps isolated from the first and second metacarpal bones was evaluated. To assess the results of treatment, X-ray monitoring of scaphoid nonunion consolidation was used at 8, 12 weeks and 6 months after surgery; computed tomography of wrist joints was performed at 4 months after surgery in order to assess the degree of bone graft reconstruction. Hand function was assessed before and after surgery using the DASH Upper Limb Disability Questionnaire and the Visual Analog Pain Scale (VAS). Results of the study: in the experimental group, scaphoid nonunion consolidation was achieved in 13 out of 15 patients (86.6%) compared with the control group (10 out of 15 patients – 66.7%). According to the severity of the pain syndrome and the final functional result, comparable indicators were obtained in both groups. Discussion: given the small sample of patients who participated in the work, the study has moderate reliability. However, the data obtained allow us to hope for the effectiveness of the proposed method of surgical treatment used in patients of the main study group.
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Matano, Fumihiro, Yohei Nounaka, and Yasuo Murai. "Frontal sinus mucosa suture closure technique for prevention of cerebrospinal fluid rhinorrhea after bifrontal craniotomy: long-term follow-up results." Neurosurgical Focus 58, no. 2 (2025): E10. https://doi.org/10.3171/2024.11.focus24703.
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OBJECTIVE Bifrontal craniotomy often involves the bony opening and mucosal disruption of the frontal sinus (FS), which can lead to cerebrospinal fluid (CSF) leakage and meningitis. These complications are particularly associated with surgical treatments for skull base tumors and anterior cerebral artery aneurysms. The authors initially reported on the basic technique in 2014 with 51 cases. This study presents a detailed description of their technique and postoperative management for sealing the exposed FS during bifrontal craniotomy, including long-term follow-up results and outcomes. To objectively evaluate the effectiveness of suturing FS mucosa in preventing CSF leakage during bilateral frontal craniotomy, the authors focused only on anterior cerebral artery aneurysms. This limitation was necessary as other conditions, like extensive tumors or trauma, might lack intact FS mucosa or require its removal due to infection. METHODS The records of 34 consecutive patients (median age 62.0 years, mean 60.4 years, range 33–78 years) who underwent bifrontal craniotomy for anterior cerebral artery aneurysms between January 2014 and December 2023 were retrospectively analyzed. All patients had bony opening and mucosal injury of the FS (with exposure to the nasal cavity) that required mucosal suturing. This technique for sealing the exposed FS involves careful dissection of the mucosa from the entire sinus, sterilization with iodine-soaked surgical cotton, and preparation for closure. After the microsurgical procedure is completed, the exposed mucosa is sealed with 6-0 nylon sutures and further secured with fibrin glue–soaked Gelfoam. The bony exposure is covered with an autologous bone flap created from the inner table of the craniotomy bone flap. Finally, the frontal periosteal flap is sutured to the frontal base dura mater. Patients were instructed not to blow their noses for 2 months postoperatively. RESULTS Two patients experienced transient non-CSF leakage from the nasal cavity, likely due to irrigation fluid, which resolved within 2 days postoperatively. No recurrence was observed during a mean follow-up period of 52.8 ± 41.7 months (median 49 months, range 3–127 months). No cases of meningitis or other intracranial infections were reported. CONCLUSIONS The long-term results demonstrate the sustained effectiveness of this technique in preventing postoperative complications related to FS exposure during bifrontal craniotomy.
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Carmichael, Daniel T. "Surgical Extraction of the Maxillary Fourth Premolar Tooth in the Dog." Journal of Veterinary Dentistry 19, no. 4 (2002): 231–33. http://dx.doi.org/10.1177/0898756420021904231.
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Dental extraction is indicated for end-stage periodontal disease, fractured teeth with exposed pulp (when endodontic treatment is not possible), retained deciduous teeth, crowded or malpositioned teeth, and in other select cases. Chewing hard objects is the most common etiology for fracture of the maxillary fourth premolar tooth in dogs. Extraction of the maxillary fourth premolar tooth is a surgical procedure. The extraction procedure involves: creating a mucoperiosteal flap, removing buccal alveolar bone, and sectioning the tooth to facilitate elevation of its three separate roots. Crown sectioning is generally recommended for multirooted teeth in order to decrease the difficulty of extraction. Sectioning should be performed at the furcation(s) to transform a large multirooted tooth into multiple, single crown-root segments that are more easily extracted. In the method described here, sectioning of the mesial root trunk is preceded by amputation of the mesial cusp to allow for more accurate sectioning at the mesial furcation. Removal of buccal alveolar bone, crown sectioning, and controlled elevation of tooth crown-root segments minimizes operative complications including root fragmentation, infraorbital artery and nerve injury, penetration of the nasal cavity, and ocular trauma. Other procedural recommendations include alveoloplasty performed with a #4 round bur and a high-speed handpiece to remove any rough or sharp bony projections at the extraction site. Alveoloplasty is complete when digital palpation of the extraction site indicates no sharp projections Finally, the alveolus is irrigated with 0.12 % chlorhexidine solution to decrease bacterial contamination and remove any debris. Primary wound apposition is recommended to reduce postoperative hemorrhage and promote early wound healing. Tension-free wound closure may be facilitated by incising the periosteal attachment in order to mobilize the mucoperiosteal flap. Surgical extraction of the maxillary fourth premolar, including the mesial cusp amputation technique, is described step-by-step.
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Kumta, Samir, Sudhir Warrier, Leena Jain, Rani Ummal, Manik Menezes, and Shrirang Purohit. "Medial femoral condyle vascularised corticoperiosteal graft: A suitable choice for scaphoid non-union." Indian Journal of Plastic Surgery 50, no. 02 (2017): 138–47. http://dx.doi.org/10.4103/ijps.ijps_62_17.
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ABSTRACT Introduction: Scaphoid fractures are not very common and frequently remain undiagnosed, presenting in non-union and persistent wrist pain. Options for scaphoid fracture treatment have been described over several decades, however, none with an optimal solution to achieve union along with good hand function. We describe here, the use of vascularised corticoperiosteal bone grafts from the medial femoral condyle (MFC) as a solution for the difficult problem of scaphoid fracture non-union. Materials and Methods: This series has 11 patients with non-union following a scaphoid fracture treated over 18 months ranging from January 2014 to January 2016 using a vascularised corticoperiosteal graft from the MFC. Bone graft fixation was done using K-wires and anastomosis was done with the radial vessels. Results: There were no cases of flap loss. Time of union was an average 3 months. All patients had a full range of movements. Discussion: MFC is an ideal site for harvesting vascularised corticoperiosteal grafts providing a large surface of tissue supplied by a rich periosteal plexus from the descending genicular artery. No significant donor site morbidities have been reported in any series in the past. The well-defined anatomy helps in a rather simple dissection. Corticoperiosteal grafts have a high osteogenic potential and hence, this vascularised graft seems ideal for small bone non-unions. Conclusion: Thin, pliable and highly vascularised corticocancellous grafts can be obtained from the MFC as an optimal treatment option for scaphoid non-unions.
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Gibb, Alan G., Kun Kiaang Tan, and Roland S. T. Sim. "The Singapore swing." Journal of Laryngology & Otology 111, no. 6 (1997): 527–30. http://dx.doi.org/10.1017/s0022215100137831.
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AbstractThe use of a rotation pedicled flap, entitled the ‘Singapore Swing’, comprising temporalis fascia and mastoid periosteum, is presented as a new method of promoting healing in ‘open’ mastoid surgery for chronic ear discharge. Cadaver studies show that the main blood supply of the flap is derived from a branch of the postauricular artery which enters the pedicle near the mastoid tip. A review of the first 14 operations showed complete healing with dry ears and intact tympanic membranes in all instances, three cases requiring secondary grafting of residual perforations. We consider the results sufficiently encouraging to merit an extended trial ofthe technique.
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Kamch, H. El, Achraf Brahmi, Anas Mesbahi, et al. "The Use of the Galea Flap for the Reconstruction of Forehead Defects." SAS Journal of Surgery 10, no. 05 (2024): 556–61. http://dx.doi.org/10.36347/sasjs.2024.v10i05.007.
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The forehead, a vital anatomical unit of the face, is delimited by the anterior hairline superiorly and by the nasal root, eyebrows, and a horizontal line through the lateral canthus inferiorly. Malignant tumors like basal cell carcinomas frequently afflict this region, necessitating meticulous reconstruction techniques to preserve aesthetics and functionality. This article presents an in-depth exploration of the galea flap graft’s efficacy in addressing tissue defect on the forehead, especially in cases of basal cell carcinomas. The surgical procedure involves a wide excision with a 1 cm safety margin, including the frontal muscle and periosteum, followed by exposing the frontal bone. A meticulous approach is taken in tracing the midline, marking the hairline, and planning the left hemi coronal incision to ensure optimal outcomes. The galea flap, vascularized by branches of the superficial temporal artery, is meticulously lifted and transposed downwards to cover the tissue defect, while ensuring the viability of the flap. Postoperative monitoring reveals no signs of cutaneous or vascular damage, with preserved sensory and motor functions attributed to the preservation of the frontal branch of the facial nerve. The discussion delves into the intricate anatomy of the forehead, emphasizing its vascularization, innvervation, and aesthetic subunits such as the glabella and eyebrows. Various surgical techniques, including direct suturing, directed healing, skin grafts, advancement flaps, and two-stage scalp flaps, are examined in light of their efficacy and limitations in forehead reconstruction. The galea flap emerges as a preferred option due to its reliable vascular supply, ease of lifting, and versatility in covering tissue defects while preserving aesthetics. Future research directions are suggested, focusing on refining surgical techniques to achieve optimal outcomes in forehead tissue reconstruction, balancing esthetic results with functional integrit.
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Bartel, Ricardo, Francesc Cruellas, Xavier Gonzalez-Compta, et al. "Mastoid obliteration and canal wall reconstruction with posterior auricular artery (PAA) fascia-periosteum flap." Acta Otorrinolaringologica (English Edition) 74, no. 1 (2023): 1–7. http://dx.doi.org/10.1016/j.otoeng.2021.07.006.
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Benet, Arnau, Halima Tabani, Xinmin Ding, et al. "The transperiosteal “inside-out” occipital artery harvesting technique." Journal of Neurosurgery 130, no. 1 (2018): 207–12. http://dx.doi.org/10.3171/2017.6.jns17518.
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OBJECTIVEThe occipital artery (OA) is a frequently used donor vessel for posterior circulation bypass procedures due to its proximity to the recipient vessels and its optimal caliber, length, and flow rate. However, its tortuous course through multiple layers of suboccipital muscles necessitates layer-by-layer dissection. The authors of this cadaveric study aimed to describe a landmark-based novel anterograde approach to harvest OA in a proximal-to-distal “inside-out” fashion, which avoids multilayer dissection.METHODSSixteen cadaveric specimens were prepared for surgical simulation, and the OA was harvested using the classic (n = 2) and novel (n = 14) techniques. The specimens were positioned three-quarters prone, with 45° contralateral head rotation. An inverted hockey-stick incision was made from the spinous process of C-2 to the mastoid tip, and the distal part of the OA was divided to lift up a myocutaneous flap, including the nuchal muscles. The OA was identified using the occipital groove (OG), the digastric muscle (DM) and its groove (DG), and the superior oblique muscle (SOM) as key landmarks. The OA was harvested anterogradely from the OG and within the flap until the skin incision was reached (proximal-to-distal technique). In addition, 35 dry skulls were assessed bilaterally (n = 70) to study additional craniometric landmarks to infer the course of the OA in the OG.RESULTSThe OA was consistently found running in the OG, which was found between the posterior belly of the DM and the SOM. The mean total length of the mobilized OA was 12.8 ± 1.2 cm, with a diameter of 1.3 ± 0.1 mm at the suboccipital segment and 1.1 ± 0.1 mm at the skin incision. On dry skulls, the occipitomastoid suture (OMS) was found to be medial to the OG in the majority of the cases (68.6%), making it a useful landmark to locate the OG and thus the proximal OA.CONCLUSIONSThe anterograde transperiosteal inside-out approach for harvesting the OA is a fast and easy technique. It requires only superficial dissection because the OA is found directly under the periosteum throughout its course, obviating tedious layer-by-layer muscle dissection. This approach avoids critical neurovascular structures like the vertebral artery. The key landmarks needed to localize the OA using this technique include the OMS, OG, DM and DG, and SOM.
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Saquian, Florence Yul N. "Basal Cell Carcinoma of the Lip and Mentum." Philippine Journal of Otolaryngology-Head and Neck Surgery 21, no. 1-2 (2005): 52–54. http://dx.doi.org/10.32412/pjohns.v21i1-2.841.
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 CASE
 A 52-year-old non-diabetic female presented with a 20-year history of hyperpigmented lower lip ulcer which gradually involved the mentum, and on punch biopsy revealed basal cell carcinoma. As a housewife, she had no excessive exposure to sunlight or radiation, and no family history of cancer. On examination, a non-healing ulcer with hyperpigmented rolled-up borders had eroded the lower lip and mentum, extending into the alveolus and mandible. Wide excision with segmental mandibulectomy, bilateral supraomohyoid neck dissection and pectoralis major myocutaneous flap reconstruction were performed and radiotherapy scheduled 6 weeks after surgery.
 Basal cell carcinoma (BCC) is the most common skin malignancy with estimated annual incidences of 1 million, over 500,000 and 190,000 in the USA, Europe and Australia, respectively1. More than 60% of all skin cancers in the Philippines are basal cell carcinoma2.
 A slow-growing, locally invasive malignant epidermal tumor, it infiltrates tissues in a three-dimensional contiguous fashion through the irregular growth of sub-clinical fingerlike outgrowths3. It rarely metastasizes, with morbidity related to local tissue invasion and destruction4. Most can be treated easily with a high cure rate; however, there are some lesions that are much more aggressive. Advanced basal cell cancers may be arbitrarily defined as tumors > 2cm; that invade bone, muscle, or nerves; that have lymph node metastasis; or that require removal of a cosmetic or functional unit5. Complications are highlighted when lesions occur in the face, particularly near orifices of the eyes, nose, ears and mouth. As with lesions close to vital structures, these pose a greater clinical challenge4.
 BCCs develop from pluripotential cells in the basal layer of the epidermis. Ultraviolet induced mutations in the TP53 tumor-suppressor gene, which resides on chromosome arm 17p, have been implicated in some cases of BCC. Furthermore, the loss of inhibition of the patched/hedgehog pathway also appears to play a role in development of BCCs and influences differentiation of a variety of tissues during fetal development6.
 Recognizing the various histological subtypes of BCC is important because aggressive therapy is often necessary for some variants3. Nodular BCC appear as waxy or pearly papules with central depression, erosion or ulceration, bleeding or crusting, and rolled (raised) borders. Tumor cells typically have large, hyperchromatic, oval nuclei and little cytoplasm. Cells appear uniform, with few mitotic figures. Pigmented BCC contain increased brown or black pigment and are most common in individuals with dark skin. Superficial BCC appears as scaly patches or papules that are pink to red-brown, often with central clearing, commonly with a threadlike border, may mimic psoriasis or eczema, but they are slowly progressive. Micronodular BCC, an aggressive subtype, is not prone to ulceration, it may appear yellow-white when stretched, firm to touch, and may have a seemingly well-defined border. Morpheaform and infiltrating BCC present with sclerotic (scarlike) plaques or papules with ill defined borders extending beyond clinical margins. Ulceration, bleeding, and crusting are uncommon. It may be mistaken for scar tissue7.
 Treatment is based on clinical diagnosis and a pre-operative biopsy3. A complete history relating the onset and rate of growth of the lesion as well as sun and radiation exposure should be taken. It is also necessary to examine and palpate the extent of lesion, with special attention given to high risk areas. Large extensive lesions may require radiographic examinations such as MRI or CT to assess soft tissue or bony involvement, respectively8. The most appropriate treatment options should be discussed with the patient. Co-morbidities may influence the choice between surgical and non-surgical treatment. Elderly patients with symptomatic and high-risk tumors may opt for less aggressive treatment options, which are palliative in intent3.
 Various surgical and non-surgical treatments are currently available. Non-surgical techniques include thrice-weekly intralesional injection of human recombinant interferon -2 for three weeks for low-risk BCCs. This option is still investigational, unlikely to benefit high-risk tumor patients, and may be expensive and time-consuming3. Photodynamic and oral retinoid therapies are other options undergoing investigation and are not yet widely available3. Radiotherapy is an extremely useful form of treatment, but faces the same problem of accurately identifying tumor margins as standard excisional surgery9. It has been used to treat many types of BCC, including those with bony and cartilaginous involvement, but is less suitable for treating large tumors in critical sites, as these are often resistant and require radiation doses that closely approach tissue tolerance3.
 Topical treatment options have been used in patients with contraindications for surgery and with lesions not entirely amenable to extirpative excision. 5-flourouracil (5FU) has been used for lowrisk, extrafacial BCC with unexciting results2,3. Imiquimod (an immune response modifier) 5% cream has been used alone and as adjunct to Mohs’ microsurgery for the treatment of BCC, with reported regression but not complete eradication of the tumor. Topical neomycin was also reported to cause regression in one case3. A prospective study involving topical application of Cashew nut extract (DeBCC®) on 14 patients with BCC in different parts of the face had no detected recurrences on follow – up periods of 11 – 49 months (28.7 months)2.
 Excisional surgery removes the tumor entirely with a peripheral margin of normal tissue. For small lesions in the face, wide excision with adequate margins is sufficient, and various reconstructive methods can be used depending on the location of the lesion. Larger lesions which involve deeper structures such as bone, warrant more radical approaches to ensure adequate margins10. In our patient, infiltration of skin, mucosa, muscle, alveolus and mandible led to a segmental mandibulectomy and subsequent reconstruction.
 Mandibular reconstruction aims to reconstitute the mandibular arch. Anterior defects result in the worst functional defects with the so-called “Andy Gump” deformity11. The preferred method for reconstructing anterior mandibular defects uses osseocutaneous free flaps, with the fibular free flap being most popular. The peroneal vessels act as the major blood supply to the periosteum in a segmental fashion allowing for multiple osteotomies, which are required for bone shaping with anterior defects. For reconstruction of the intra-oral structures, a large soft tissue paddle based on septal and intramuscular perforators can be used, and osteointegrated implants can be placed in the bone graft12.
 Another option for reconstruction is a pedicled flap, and the more commonly used is the pectoralis major osteomyocutaneous flap. Its dominant pedicle is the thoracoacromial artery and vein that runs on the undersurface of the muscle. The underlying rib is also harvested to reconstitute the mandible13. The advantages of pedicled flaps include less morbidity, shorter operative time, and a more definitve blood supply, which ensures the survival of the skin flap and bone11. However, these flaps tend to be difficult to harvest and have limited arcs of rotation and limited bone graft mobility relative to the soft tissue portion of the flap. The blood supply of the bony portion is often tenuous following transfer, and the lack of bony bulk limits dental rehabilitation12.
 Postoperative management of flap reconstruction includes gentle cleansing and application of topical antibiotics. Diligent oral hygiene offsets potential complications from post operative drooling. Partial or total flap failure is a common postoperative concern. Partial distal flap necrosis can be managed expectantly. Cyanosis may be due to excessive wound tension or vascular pedicle compromise, and should be explored as necessary15.
 
 Acknowledgement :
 We thank Dr. Camille Sidonie A. Espina for providing the case for discussion.
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Dzonov, Boro, Lazo Noveski, Suzana Nikolovska, and Elizabeta Zhogovska. "Doppler Comparative Measurements in the Reconstruction of Limbs with Flaps and Grafts." Macedonian Medical Review 71, no. 1 (2017): 56–63. http://dx.doi.org/10.1515/mmr-2017-0011.
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Abstract Doppler technique was first described by the Australian physicist and mathematician Christian Doppler. Doppler effect is defined as a reflection of high frequency sound waves of different frequency when they come in contact with the movable structure in the blood vessel. Waves that go to transducers are coded red, while waves that move away from the transducer are coded blue. Doppler main types can be classified as following: continuous wave (CW) Doppler, spectral Doppler, color Doppler and Power Doppler color. The study was realizedat the University Clinic for Plastic and Reconstructive Surgery. It is a randomized prospective study. During the study two groups of 30 patientseach were formed. Each patient was required a permission for reconstructive surgery procedure and an informed consent for participation in the study. For all patients a specially designed questionnaire (non-standardized) was filled out. 1. First (I) group of patients treated with flaps. In this group a type of reconstructive technique with skin or complex flapshas been applied. 2. Second group (II) of patients treated with grafts (split thickness grafts). In this group applied reconstruction comprised application of skin grafts with partial thickness. The study included patients with defects of the skin and soft tissues, whohad an indication for reconstructive surgery procedure. Exclusion criteria of patients for participation in the study were: children under 14 years of age, adults over 75 years, people with systemic diseases that can affect the results of reconstructive intervenetions and patients who have without periosteum bone-like surface defect as contraindication for skin grafting. The results of the reconstructive procedures according to the objectives set were investigated clinically into three time periods: preoperative, postoperative day 7 and day 30 postoperatively. The following investigations were carried out: determination of the circulation levels by means of Doppler; determination of the levels of limbs circulation is distal to the site of reconstruction in the pre-and postoperative period (day 7 and day 30); For the evaluation of blood flow the following parameters were used: • PSV-Peak systolic velocity • PI - Pulsatility index RI - Resistance indexPI and RI were calculated using the formula: • PI = PSV - EDV / Vmean • RI = PSV - EDV / PSV EDV indicates the flow velocity in late diastole and V mean, the average speed of blood flow through the artery. By assessment of arterial status before and after surgery through the analysis ofvascular waves at different locations of the vascular tree of the upper and lower extremities, we registered significant difference between the two examined groups, which speaks in favor of the use of flaps in reconstruction of the lower limbs.
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Giesen, Thomas, Francesco Costa, and Elmar Fritsche. "Complex reconstruction of the clavicle with a prefabricated medial femur condyle chimeric flap including a superficial circumflex iliac artery perforator flap: A case report." Microsurgery, September 5, 2023. http://dx.doi.org/10.1002/micr.31108.
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AbstractThe medial femur condyle (MFC) cortico‐periosteal flap is a popular flap for bone reconstruction. The use of a chimeric version of this flap with a skin island has been described, but anatomical arterial variation can occur that prevent its harvest. Furthermore, the donor area of the skin paddle has been debated as poor because of the scarring in a visible area and because of the difficulty in obtaining pliable thin skin. We present a fabricated chimeric MFC cortico‐periosteal flap joined with a superficial inferior epigastric perforator (SCIP) flap to reconstruct and augment a sclerotic and insufficient small clavicula with the skin paddle acting as a monitor and as a substitute for the overlying skin. A 52‐year‐old female patient had a history of multiple refractures of the right hypoplastic clavicle with a diameter of 7 mm, resulting in a sclerotic bone with a fibrotic scar. The reconstruction was done in one surgical session using a cortico‐periosteal flap from the left medial condyle and a thin SCIP flap from the left groin. The area of the clavicle to be reconstructed was 3 cm, and the direct overlying skin (approximately 6 × 3 cm) was severely scarred and painful. The MFC flap was 5 × 4 cm, while the SCIP flap was 7 × 3.5 cm. The SCIP flap artery was anastomosed on the table end‐to‐side to the descending genicular (DG) artery of the MFC, and the vein was anastomosed end‐to‐end to a comitans vein of the DG artery. The flap fully survived after an initial congestion. At 12 months, we observed a satisfactory reconstruction of the clavicle with an enhanced diameter of 12 mm. The patient recovered full function of the shoulder with no pain. Using a fabricated chimeric flap composed of a medial femoral condyle and a superficial circumflex artery perforator flap may be an additional option for tailored reconstruction of complex osteo‐cutaneous defect of clavicle.
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Arcuri, Francesco, Francesco Laganà, Bernardo Bianchi, Silvano Ferrari, and Andrea Ferri. "Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction." Journal of Craniofacial Surgery, July 10, 2023. http://dx.doi.org/10.1097/scs.0000000000009512.
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Introduction: Scapular tip free flap (STFF) has become today one of the workhorse flaps for maxillary reconstruction; recently, the possibility of extending the vascular supply by adding to the angular branch of the circumflex pedicle up to its periosteal entrance in the lateral border of the scapula has been proposed as a reliable technique to improve the length of perfused bone when STFF is used for mandibular reconstruction. The purpose of this study was to evaluate the patients who had received microvascular reconstruction of the mandible with STFF vascularized by both the circumflex scapular artery via the periosteal branch and the thoracodorsal artery via the angular artery. Methods: A retrospective chart review was conducted for all patients who underwent reconstruction with an STFF for mandibular defect between January 2016 and December 2020 at the University Hospital of Parma. The outcome was evaluated by assessing dietary intake (unrestricted, soft, liquid, and tube feed) and speech (normal, intelligible, partially intelligible, and unintelligible). Results: The final study sample included 9 patients (5 men and 4 women). The average patient age was 68.9 years (range, 59.9–74.8 y) at the time of surgery. There was no flap loss. A 1-year postoperative computed tomography scan revealed full osteointegration of the flap. Conclusions: Our results show that the STFF is a valuable reconstructive option, especially in patients with complex head and neck defects requiring soft and hard tissues.
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Burlage, Laura C., Liron Duraku, Tim Wang, and Brahman Shankar Sivakumar. "Proximal Olecranon Free Flap for Cystic Scaphoid Nonunion: An Anatomical Feasibility Study." HAND, April 23, 2025. https://doi.org/10.1177/15589447251329569.
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Background: The treatment of scaphoid nonunion is challenging, with one approach aiming to provide vascularized bone to encourage union. While the iliac crest and medial femoral condyle are well-described donor sites for osseous flaps, they require violation of a separate limb and confer particular donor site morbidities. We investigate the viability of using a proximal olecranon osseous free flap in the setting of scaphoid nonunion. Methods: Ten proximal olecranon free flaps were harvested in cadaveric specimens, and the length of the pedicle, diameter of the pedicle, number of perforators and quality of bone graft harvested were recorded. Furthermore, a volar approach to the scaphoid was performed, and the shortest distance from the scaphoid to the radial artery noted, to determine whether utilization of the olecranon free flap was possible without grafting. Results: The posterior ulnar recurrent artery [PURA] was present in all specimens. The median pedicle length from take-off of the PURA to the olecranon flap was 65 (62.2-71.0) mm. The number of visible periosteal perforators varied between 1 and 2 per specimen. The median diameter of the main perforator before dividing into subperiosteal branches was 2 (2.1-2.5) mm. The quality of the bone graft harvested was mainly assessed as good (n = 5) or moderate (n = 4). The mean shortest distance from scaphoid to radial artery was 10 mm. Conclusions: The olecranon free flap is a suitable alternative source of vascularized bone for scaphoid nonunion.
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Hurrell, Michael J. L., David Leinkram, Murray J. Stokan, and Jonathan R. Clark. "Medial Femoral Condyle Periosteal Free Flap for Bone Coverage Following Debridement of Intermediate-Stage Osteoradionecrosis of the Jaw." Journal of Craniofacial Surgery, April 18, 2024. http://dx.doi.org/10.1097/scs.0000000000010059.
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Study design: Case report. Osteoradionecrosis (ORN) of the jaw is a potentially devastating consequence of head and neck irradiation. The progression of ORN can lead to loss of bone, teeth, soft tissue necrosis, pathologic fracture, and oro-cutaneous fistula. Reconstructive surgery has mostly been reserved for late-stage disease where segmental resections are frequently necessary. Evidence is emerging to support earlier treatment in the form of debridement in combination with soft tissue free flaps for intermediate-stage ORN. The authors present a case of a 76-year-old male with persistent Notani 2 ORN of the mandible, treated with surgical removal of all remaining mandibular teeth, transoral debridement of all necrotic mandibular bone, and bone coverage with a left medial femoral condyle (MFC) periosteal free flap based on the descending genicular artery. Treatment was uneventful both intraoperatively and postoperatively. Since surgery (15 mo) the patient has remained free from clinical and radiologic signs of ORN. The MFP periosteal free flap provided an excellent result with minimal surgical complexity and morbidity in this case. Such treatment at an intermediate stage likely results in a reduction in segmental resections, less donor site morbidity, less operative time, less overall treatment time, and possibly fewer postoperative complications compared with the status quo.
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Knitschke, Michael, Anna Katrin Baumgart, Christina Bäcker, et al. "Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning." Frontiers in Oncology 11 (January 19, 2022). http://dx.doi.org/10.3389/fonc.2021.821851.
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BackgroundVirtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.MethodThis retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.ResultA total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs’ vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.ConclusionIn general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.
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Boghossian, Elie, and David A. Stewart. "The Medial Metaphyseal Periosteal Artery (MMPA): An Alternate Pedicle for the Medial Femoral Trochlea Flap." Journal of Hand Surgery, January 2021. http://dx.doi.org/10.1016/j.jhsa.2020.11.012.
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Omura, Kazuhiro, Adam J. Kimple, Brent A. Senior, et al. "Minimally invasive trans-nasal approach to the anteromedial temporal fossa and lateral sphenoid using a novel landmark between periorbita and periosteum of pterygopalatine fossa: a cadaveric study." Journal of Neurological Surgery Part B: Skull Base, May 26, 2023. http://dx.doi.org/10.1055/a-2101-9910.
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The anteromedial temporal region and lateral wall of the sphenoid sinus, in which the second and third divisions of the trigeminal nerve (V2, V3), internal carotid artery, cavernous sinus, and temporal lobe exist can be the site of an array of pathology including trigeminal schwannoma, encephalocele, cholesterol granuloma of the petrous apex, malignancy with or without perineural spread, infection, and sellar pathology extending to the lateral cavernous sinus. Approaches to this region are technically challenging and the existing approach requires sacrifice of the all of the turbinate include nasolacrimal duct, which can cause postoperative complications. We describe a novel anatomical landmark between the periorbita and periosteum of the pterygopalatine fossa (which is located at the inferior lateral periorbital periosteal line: ILPPL). The posterior one third of the incision line lies between the foramen rotundum and superior orbital fissure, which is proximity of the maxillary strut Using a 1.5-cm incision can divide the orbital and pterygoid contents and lead us to the posterior infra-lateral orbital region, antero-medial temporal region, lateral wall of the sphenoid sinus, and lateral wall of cavernous sinus. Combined with multi- angled approach with ILPPL enable us to preserve all of the turbinates and septum, nasolacrimal duct allowing for the preservation of physiological function and pedicled flaps, such as the middle turbinate, inferior turbinate, and septum membrane flap. The ILPPL is a simple, effective, and novel landmark for the minimally invasive approach to the anteromedial temporal fossa.
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Barrera-Ochoa, Sergi, Julio A. Martínez-Garza, Maximiliano Ibañez, José A. Prieto-Mere, Melissa Bonilla-Chaperon, and Francisco Soldado. "Vascularized Proximal Radius Bone Graft for a Massive Elbow Bone Defect: An Anatomic Study and Case Report." Techniques in Hand & Upper Extremity Surgery, February 10, 2025. https://doi.org/10.1097/bth.0000000000000508.
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From an anatomic perspective, this paper delineates the proximal radial bone branches of the radial artery (RA). We also report the successful clinical use of a vascularized proximal radius bone graft (VPRBG), supplied by the RA, in a complex case involving a massive osseous elbow defect. In 10 latex-colored upper limbs from fresh human cadavers, RA branches were dissected under ×2.5 loupe magnification, noting all periosteal and osseous branches for the proximal radius. VPRBG length was measured. In the proximal forearm, the RA provides 10 (range: 7 to 14) periosteal and osseous branches to supply the area from the radial head to the proximal diaphysis. A 15 cm (11 to 17) vascularized bone graft can be harvested from the proximal radius, and RA dissection generates a 12 cm (9 to 15) pedicle with a wide arc of rotation, readily capable of reaching the distal part of the humerus. We used a 14 cm long VPRBG for elbow arthrodesis to fill a 12 cm defect, caused by a previous recalcitrant elbow infection in a 68-year-old man. The patient experienced no postoperative complications and successful consolidation was achieved 6 months postoperatively, with flap survival confirmed. After 2 years of follow-up, the contoured dorsal plate was removed, with no signs of infection. Final Disabilities of the Arm, Shoulder, and Hand and Mayo Wrist scores were 23 and 88, respectively. A VPRBG might be a safe and effective surgical option for massive osseous elbow defects, whenever elbow arthrodesis is planned, where it should be combined with a one-bone forearm technique.
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Sfondrini, Domenico, Stefano Marelli, Rachele Patriarca, et al. "Floor of the Mouth Hemorrhage Following Dental Implant Placement or Guided Bone Regeneration (GBR) in the Atrophic Interforaminal Mandible." Case Reports in Dentistry 2024, no. 1 (2024). https://doi.org/10.1155/crid/8413875.
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The authors present two cases of mouth floor hemorrhage consequences of implant placement within the atrophic anterior mandible. In one patient, the implant placement was associated with the guided bone regeneration (GBR) technique. This serious complication has been widely described in the literature, especially in the anterior mandible area. In cases of bone resorption, the edentulous ridge becomes closer to the artery, and the risk of vessel injury increases. In both patients, the hematoma rapidly spread in the loose tissues of the mouth floor, displacing the tongue posteriorly and cranially, with airway compromise. The patients were hospitalized with nasotracheal intubation to secure the airway. In both patients, the bleeding stopped spontaneously, and after a few days, the oral floor swallowing was reduced, allowing the endotracheal tube to be removed. In about 2 weeks, the hematoma completely resorbed without surgery. According to the literature, the main cause of floor of the mouth hemorrhage is the mandibular lingual cortical plate perforation during bone drilling with subsequent sublingual–submental artery injury. In fact, in the first patient presented, this surgical error was clearly noticeable on the CT scan. Differently, in the second case reported, no radiological signs of inner cortical perforation were observed, and together with a mouth floor hematoma, a blood collection was also evident on the lower lip, suggesting a different cause of bleeding. Most likely during the periosteal release incision, mandatory in GBR technique, the ascending mental artery was injured, and hematoma spread in the mouth floor through the similar incision done on the lingual flap. Firstly, the mouth floor hemorrhage caused by an injury of a vestibular soft tissue artery during GBR surgery was reported. Strategies and recommendations to avoid this life‐threatening event are provided, based on the literature review and the authors’ experience.
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Cinclair, Trey, Lindsey Urquia, Austin Hembd, and Shelby Lies. "Pedicled Pronator Quadratus Transposition for Functional Opponensplasty: A Cadaveric Anatomical Study for Feasibility." HAND, February 14, 2023, 155894472311531. http://dx.doi.org/10.1177/15589447231153177.
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Background: Techniques on opponensplasty for chronic carpal tunnel syndrome have been described previously. A novel pronator quadratus (PQ) transposition for chronic carpal tunnel syndrome is described. In addition, the relationship of the distal perforating branch of the radial artery to the surrounding tissue is detailed to optimize further use of the PQ flap for clinical applications. Methods: Ten cadaver hands underwent PQ dissection, and the perforating branch of the radial artery was identified. Measurements were taken from the radiocarpal joint and the radial styloid to the distal perforating branch. Finally, a proposed surgical technique of PQ transposition with proximal radius periosteum to the first metacarpophalangeal joint and anterior interosseous nerve transfer was performed. Results: The average distance of the perforating branch from the radiocarpal joint was 10 ± 1.05 mm, and the average distance from the radial styloid was 17.1 ± 1.6 mm. Pronator quadratus transposed with a layer of radius periosteum demonstrated anatomical feasibility. Conclusions: The distal perforating branch of the radial artery predictably perfuses the PQ muscle, which may be used in the future as a means of opponensplasty for chronic carpal tunnel syndrome.
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Bartel, Ricardo, Francesc Cruellas, Xavier Gonzalez-Compta, et al. "Mastoid obliteration and canal wall reconstruction with posterior auricular artery (PAA) fascia-periosteum flap." Acta Otorrinolaringológica Española, December 2021. http://dx.doi.org/10.1016/j.otorri.2021.07.003.
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Kaiser, Dominik, and L. Scott Levin. "Medial Femoral Condyle Free Flap for Persistent Osseous Nonunion of the First Metatarsophalangeal Joint: A Preliminary Report of a New Surgical Indication for the Medial Femoral Condyle Free Flap." Foot & Ankle Orthopaedics 8, no. 3 (2023). http://dx.doi.org/10.1177/24730114231191135.
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Background: Recalcitrant or persistent nonunions of the metatarsophalangeal (MTP) joint occur following failed MTP surgery for MTP fusion, failed MTP prosthesis, for hallux rigidus or due to infection and erosion. A deficient soft tissue envelope and compromised vascular supply of tissues in this region compound further attempts to salvage the great toe and preserve function. The medial femoral condyle (MFC) free flap provides vascularized corticocancellous bone and periosteum and has been successfully used for a variety of complex hindfoot and ankle pathologies. We present an additional indication with a small cohort study demonstrating its use in persistent nonunions of the first MTP joint. Methods: A retrospective review was completed of all MFC flaps used for revision of failed first MTP joint fusion from January 2019 to November 2022. Demographic information, comorbidities, as well as clinical and radiologic follow-up was obtained from the patient charts. Results: Three patients were included with MTP nonunion and an average of 7.5 (range, 5-11) failed prior surgeries. Mean age at index surgery was 50 (range, 46-57) years. An osseous union was achieved in all patients after 82 (range, 75-88) days. Hardware removal was possible after 81 (range, 55-98) days. Mean follow-up was 17 (range, 5-31) months. We note a 100% flap success rate without returns to the operating room. The lengths of the bone flaps were 2 to 4 cm, the volumes were 8 to 12 cm3. Fixation was performed with 1 intramedullary K-wire. The recipient vessel in all patients was the dorsalis pedis artery or a tributary thereof. All arterial anastomoses were performed under the operating microscope. Conclusion: The MFC free flap is a reasonable option for salvage of complex recalcitrant or persistent nonunions of the first MTP joint. More prospective long-term studies with functional outcomes are necessary to confirm these findings. Level of Evidence: Level IV, retrospective case series.
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Muangsiri, Pichtat, Rungkit Tanjapatkul, Papat Sriswadpong, Pojanan Jomkoh, and Supasid Jirawatnotai. "Indocyanine Green Fluorescence Angiography of the Transverse Cervical Arterial Supply to Clavicle Flaps: An Anatomical Study." Otolaryngology–Head and Neck Surgery, March 30, 2021, 019459982110004. http://dx.doi.org/10.1177/01945998211000432.
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Objective To describe the anatomy of the transverse cervical artery and to prove its perfusion to the clavicle using indocyanine green fluorescence angiography as an alternative vascularized bone for head and neck reconstruction. Study Design Cadaveric dissection. Setting Anatomy lab. Methods Twenty-two necks and shoulders from 11 fresh-frozen cadavers were dissected. The transverse cervical artery diameter, length, emerging point, and the length of clavicle segment harvested were described. Photographic and near-infrared video recordings of the bone’s medial and longitudinal cut surfaces were taken prior to, during, and after indocyanine green injection. Results The transverse cervical artery originated from the thyrocervical trunk and emerged at the level of the medial one-third of the clavicle in 22 of 22 (100%) specimens. The average length of the pedicle was 3.6 cm (range, 2.2-4.4 cm), and the mean diameter was 2.5 mm (range, 1.8-3.4 mm). The harvested bone had a mean length of 5.1 cm (range, 4.3-5.8 cm). After injecting the indocyanine green, 22 of 22 (100%) specimens showed enhancement in the periosteum, bony cortex, and medulla. Conclusion The middle third of the clavicle can be reliably harvested as a vascularized bone with its perfusion solely from the transverse cervical artery pedicle, as shown by the near-infrared fluorescence imaging. The pedicle was sizable and constant in origin.
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Briones, Richard C., Kathleen S. Cruz, Dave R. Resoco, and Marla Vina A. Briones. "Medusa’s Wrath: Bleeding Giant Scalp Arteriovenous Malformation in an Adult: A Case Report." Vascular and Endovascular Surgery, February 2, 2023, 153857442311549. http://dx.doi.org/10.1177/15385744231154990.
Full textAbstract:
Background Scalp arteriovenous malformation (AVM) is a rare congenital disease that may present with massive bleeding. To date, surgical excision remains the definitive management. However, the procedure could lead to intraoperative bleeding due to the tumor’s high blood flow and complex vascularity. Case Report A 49-year old Filipino male presented with a bleeding giant scalp AVM. Computed tomographic scan and duplex studies showed multiple feeding vessels with turbulent flow arising primarily from the right superficial temporal, right posterior auricular, and occipital vessels. Prior to surgery, the patient underwent transfusion due to preoperative hemoglobin of 6 g/dL. Proximal control of the right external carotid artery was performed through a supine position and left in place to reduce the majority of blood flow to the AVM. The patient was turned to a prone position for surgical planning to achieve maximal skin-sparing dissection prior to excision. First, ligation of bilateral superficial temporal and posterior auricular arteries was performed. Next, excision above the periosteum with segmental ligation of feeding vessels around the AVM was carried out. Reconstruction of the defect was done via scalp advancement flap and split-thickness skin grafting. Intraoperative blood loss was 1.6 L. On the sixth postoperative day, the patient was discharged with 100% graft take. Conclusion Management of scalp AV malformation is challenging, and despite measures to decrease intraoperative bleeding, blood loss is still high. While preoperative embolization has been reported to decrease the risk of bleeding, this procedure is not currently available in our setting. Our case highlights the complexity of giant scalp AV malformation management in a limited-resource setting. Even in the absence of endovascular intervention, outright surgical excision of AVM can be performed, albeit with higher levels of blood loss.