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Background Congenital diaphragmatic hernia (CDH) repair is technically challenging with different approaches for repair. The aim of this study was to compare outcomes between patch and flap repair. Methods CDH repairs performed at a quaternary care children's hospital between 2008 and 2018 were reviewed. Seventy CDH repairs were analyzed after primary repairs were excluded (n = 52). Analysis included proportions or median with interquartile range and chi-square or Wilcoxon rank-sum test. Results Comparing patch and flap repairs, demographic characteristics and hernia parameters were similar. Examining outcomes, length of stay, 30-day mortality, and 1-year mortality were all similar between groups, but total/symptomatic recurrence was higher in the patch group (10%/7% vs. 3%/0%), and the median time to recurrence was 3 months. A sub-analysis comparing those who recurred to those who did not demonstrated no significant difference between the two groups. Conclusion Patients who undergo flap repair have a lower risk of recurrence compared to those who undergo patch repair, and this may be due to the ability of the flap to grow over time with the child. Type of Study Treatment Study. Level of Evidence III

Truncus arteriosus with interrupted aortic arch represents a complex lesion with high rates of reintervention. We present a novel technique of a composite flap, made possible by aberrant right subclavian anatomy.

Background Removal of skin cancer at or near the vermilion border may result in a partial-thickness combined cutaneous and mucosal lip defect for which repair has potential for poor cosmetic and functional outcomes. Objective We sought to describe the closure and results from repair of combined lip defects using 2 island pedicle or V-Y flaps, 1 for the cutaneous lip and 1 for the mucosa. Methods A retrospective review of all patients with combined defects of the lip who underwent double island pedicle or V-Y flap repair from June 2008 to December 2013 was performed. Results Ten patients (6 female, 4 male; ages 35-89 years, mean age 60 years) had defects on the upper lip in 8 cases and on the lower lip in 2 cases. Follow-up was for 3 months or longer with good or excellent outcomes in all cases. Limitations This was a nonrandomized, unblinded clinical case series with a limited sample size. Conclusion Double island pedicle or V-Y flap repair is an elegant closure with good to excellent results and may avoid potential problems inherent in other repair options.

Purpose The goal in the treatment of anal fistulas is to eliminate the fistula without a change in continence. No single technique exists that is appropriate for the treatment of all fistulas. Options include fistulotomy, use of setons, fibrin sealant, and advancement flaps. Recently, a bioprosthetic fistula plug has been described. The purpose of this study is to report the author's early experience with the bioprosthetic fistula plug and to compare the results of bioprosthetic plug closure of complex anal fistulas with those achieved with advancement flap repair. Methods A retrospective analysis of prospectively collected data was performed for patients treated with an anal fistula. Data collected included age, gender, fistula anatomy and etiology, previous repairs, comorbidities, procedure performed, pain scores, and fistula recurrence. Results Overall, 95 patients comprised the control group (43 men and 52 women), with transsphincteric or rectovaginal fistulas in 51 and 44 patients, respectively, managed by advancement flap repair of their fistula. The fistula recurred in 31 patients (32.6%) during a median follow-up of 10 months. Overall,18 patients had their fistula managed using the porcine fistula plug (12 men and 6 women), with transsphincteric or rectovaginal fistulas in 13 and 5 patients, respectively. The fistula recurred in 2 patients (12%) during a median follow-up of 6 months. Conclusion Use of a porcine fistula plug for the management of complex anal fistulas is a new technique that, in the early experience, seems to yield results similar to advancement flap repair.

Introduction: Nasal valve collapse is a common cause of nasal airway obstruction. Although many techni- ques have been devised to treat this problem, the outcomes of most of them have been disappointing. The aim of this study is to report our experience using the lateral crural J- flap repair to correct the nasal valve collapse. This techni- que is based on a new view of the structural etiology of na- sal valve collapse and it offers excellent functional and aesthetic outcomes. Material and methods: We present a re- trospective study of 19 patients diagnosed of nasal valve co- llapse that underwent lateral crural J-flap repair from 2003 to 2005. Results: 28 lateral crural J-flap repairs were made. Six patients underwent concomitant nasal surgery. Mean fo- llow-up was 428 days All the patients have reported impro- vement of the subjective sensation of inspiratory collapse and there has been no noticeable decrement in benefit over time. No complications due to the procedure were obser- ved. Conclusion: The lateral crural J-flap repair is an efective treatment for nasal valve collapse with minimal morbidity

Background We investigated the correlation between operative procedures for rectal carcinoma and postoperative rectovaginal fistulas (RVF), and treatment for RVF. Methods The medical records of 161 female patients with rectal carcinoma were examined retrospectively with respect to the cause, incidence, and methods of treatment for RVF occurring after rectal cancer operations, and to the outcomes of gluteal-fold flap repairs for RVF. Results Of the 161 patients, 16 developed RVF clinically. The incidence of RVF was significantly higher in patients who were anastomosed by the double stapling technique (DST) and had concomitant resection of the vaginal wall. No statistical difference was found between the established diverting ostomy group and the no-stoma group. Six patients recovered by the establishment of a diverting ostomy only. The gluteal-fold flap technique was performed for 5 patients. No RVF recurrences were noted in these 5 patients. Conclusions The incidence of RVF was higher in the patients who were anastomosed by DST or had concomitant resection of the vaginal wall. Although some RVFs heal with only fecal diversion, for patients in whom RVF is caused by involvement of the vaginal wall in the circular staple or intersphincteric resection, good results are obtained with the gluteal-fold flap repair technique.

Summary Purpose The use of flaps in the two-stage repair of posterior hypospadias associated with severe chordee has been well established. Despite the almost certain guarantee of flap take, complications such as diverticuli are still relatively high. While different applications of the tubularized incised plate have been described, experience with the application of the technique to the two-stage flap repair is very limited. A previous local review of 15 cases performed at the present institution during the period 1998–2003, using the technique as described by Rekit, revealed fistulae and diverticulum rates of 20% and 27%, respectively. With the primary objective of improving surgical outcome, the midline incision was incorporated into the two-stage flap repair. Materials and methods Between 2004 and 2015, 35 boys (aged 2–15 years) with severe hypospadias that required excision of the urethral plate were operated using the two-stage flap technique. The first stage involved mobilization of preputeal or dorsal penile skin (if circumcised) to the ventral surface, as described by Retik. After a minimum interval of 6 months, the second-stage operation was performed in a way similar to the technique of tubularized incised plate urethroplasty, as popularized by Snodgrass, and involved a preliminary midline incision on the neo-urethral plate followed by tubularization and multilayered closure. Results All but one flap took successfully. The outcome was satisfactory in 80% of patients, and there was a fistula rate of 14% ( Summary Table). One patient had a complete breakdown of the flap and was successfully treated about 12 months later by repeating the second stage of the operation. No case of diverticulum or stricture was recorded. Discussion Even though there was a marginal improvement in the fistula rate, the most striking observation was the complete absence of diverticulum or stricture. With a reported incidence rate of 20–63%, different authors have reported diverticulum formation (despite the absence of distal obstruction) to be a major problem of the two-stage flap technique. Attempts by these authors at reducing the risk of diverticulum by reducing flap size have tended to increase the risk of strictures. This has been the main reason given by some authors for abandoning the technique. The main limitations of the present study included the wide age range of the patients and the small sample size. Conclusion The inclusion of a midline incision in a two-stage flap urethroplasty for proximal hypospadias appears to prevent the development of diverticulum. Summary Table . Outcome of treatment. Age range (years) Average duration of follow-up in months (SD) Satisfactory outcome (%) Fistula (%) Wound breakdown (%) Stream deviation (%) Total number of patients 2–5 34.0 (20.7) 16 (76) 3 (14) 1 (5) 1 (5) 21 6–10 22.6 (7.8) 10 (83) 2 (17) 0 0 12 >10 26.0 (9.9) 2 (100) 0 0 0 2

The groin flap is frequently used for covering soft-tissue defects of the hand. It is normally utilised as a single unit to cover the defect. When used for coverage of multiple digital defects, it requires syndactylisation of the digits with a further procedure to divide the syndactylised digits some time after division of the main pedicle. We report a new technique of fashioning 'daughter flaps' from the groin flap at the time of elevation, and their use to cover full-thickness burns to the dorsum of PIP joints in both hands thus avoiding the need for syndactylisation of the digits.

A preliminary report is submitted on the growth of the lip after repair of a unilateral complete cleft (with a modified rotation-advancement flap) in 20 patients. In half of these cases an additional small Z-plasty was performed. The patients were photographed by a standardized method immediately after surgery and again after 18 months. Lip length on the operated side was measured and compared with the opposite side; possible results were: equal, long and short. After 18 months, 65% of all cases remained unchanged, 25% had lengthened and 10% shortened. Among cases treated with an additional small Z-plasty, unchanged and lengthened cases had an almost equal distribution, while the majority (8 out of 10) of the cases treated without Z-plasty remained unchanged. Consequently, the authors emphasize the benefits of reconstructing the cleft lip as symmetrical to the opposite side as possible or, at the most, moderately shorter only in cases treated with an additional Z-plasty.

Despite its prevalence for more than two decades, one-stage repair of moderately severe hypospadias is still associated with a high complication rate. A retrospective study of 103 cases of posterior hypospadias treated exclusively with the Duckett transverse island flap procedure was conducted to analyze factors that might affect the morbidity. The latter included the age of the patients, the anatomical variants of the hypospadias, the suture materials and the technique used, the length of the urethral tube, and the methods and duration of urinary diversion. The fistula rate was 24% (25/103), and the overall complication rate was 31% (32/103). The patients in the glanular-subcoronal-penile variant had a significantly lower overall complication rate than those in the penoscrotal-scrotal variant (21% versus 39%, P.05). The patients with a neourethra shorter than 3 cm also had significantly less complications than those with a neourethra longer than 3 cm (25% versus 47%, P.05). The only procedural factor that makes a difference is the method of skin closure to form the neourethra. Two-layer closure resulted in a significantly lower fistula rate and overall complication rate than one-layer closure (13% versus 34% and 15% versus 45%, P.025 and P.005, respectively). The study confirms the value of two-layer closure in the transverse island flap repair of posterior hypospadias.

1. Urbanski PP. Carotid artery cannulation in acute aortic dissection with malperfu-sion. J Thorac Cardiovasc Surg. 2006;131:1398-9.2. Urbanski PP, Lenos A, Lindemann Y, Zacher M, Frank S, Diegeler A. Use ofa carotid artery for arterial cannulation: side-related differences. Thorac Cardio-vasc Surg. 2010;58:276-9.3. UrbanskiPP,LenosA,BougioukakisP,NeophytouI,ZacherM,DiegelerA.Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: a changeof paradigm? Eur J Cardiothorac Surg. 2012;41:185-91.4. Urbanski PP, Lenos A, Zacher M, Diegeler A. Unilateral cerebral perfusion: rightversus left. Eur J Cardiothorac Surg. 2010;37:1322-36.5. OrihashiK,SuedaT,OkadaK,TakahashiS.Compressedtruelumenintheinnom-inate artery: a pitfall of right axillary arterial perfusion in acute aortic dissection.J Thorac Cardiovasc Surg. 2009;137:242-3.6. Minatoya K, Ogino H, Matsuda H, Sasaki H. Rapid and safe establishment ofcardiopulmonary bypass in repair of acute aortic dissection: improved resultswith double cannulation. Interact Cardiovasc Thorac Surg. 2008;7:951-3.

There is little written in the literature regarding the management of major bronchial disruptions occurring during mediastinoscopy. This report illustrates the use of an in-continuity flap bronchoplasty of middle lobe bronchial tissue to repair such an iatrogenic intermediate bronchus injury.

A case of chylopericardium developing in a neonate after subclavian flap repair of a preductal coarctation of the aorta is reported and a review of the literature is presented.

Fifty-five infants less than 1 year of age underwent repair of coarctation of the aorta between 1967 and 1981. Sixteen (29%) died while in the hospital, with one death occurring from “pure” coarctation. Of the remaining patients, four among 20 with associated ventricular septal defect (VSD) and 11 among 19 with other major associated cardiac anomalies (p = 0.002) also died. Thirteen (62%) of 21 patients treated by resection and end-to-end anastomosis died in the hospital, while only two (7%) of 30 in whom the subclavian flap repair was used died (p

The subclavian flap repair for coarctation of the aorta allows potential for growth by utilizing autogenous tissue. Although well documented in young children, its promise in the tiny neonate warrants further evaluation. Since August, 1979, 29 patients, including 24 infants, have undergone subclavian flap repair at the University of Maryland Hospital. Weights ranged from 1.4 to 5 kg (mean 3.2 kg). AD patients less than 6 months old had associated intracardiac defects and were in severe congestive failure. Fifteen responded to preoperative prostaglandin infusions. The overall early mortality was 14%; among the neonates it was 21%; and among those operated upon within the first week of life, 33%. There was one intraoperative death among the eight patients who underwent simultaneous pulmonary artery banding. There were no deaths among patients older than 5 days at operation. Four of the five neonates who died had some variant of hypoplastic left heart syndrome, with severe stenosis or atresia of the systemic atrioventricular valve, critical aortic stenosis, or hypoplastic left ventricle. Twenty-two survivors continue to do well up to 3.7 years postoperatively (mean follow-up 26 months). At follow-up all patients are normotensive with brisk lower extremity pulses. Patients now weigh 1.3 to 6.9 (mean 2.3) times their operative weight, and only one patient has a measured arm-to-leg gradient greater than 10 mm Hg (mean gradient 3.7 mm Hg). Seven of the neonates have undergone repeat catheterization, and all had satisfactory growth of the subclavian flap segment of repair and no gradient Two older patients (3 and 4 years old at operation) have undergone exercise testing 3.7 years after repair, with peak exercise gradients of only 7 and 15 mm Hg. We therefore continue to utilize this technique for the treatment of coarctation even in tiny neonates.

In a retrospective review of 50 patients with wounds of the ear, simple closure was found preferable to flap repair as a method of primary treatment. Replantation of the partially or totally amputated ear as a composite graft was singularly unsuccessful in this series.

Recoarctation is a problem in some patients after subclavian flap aortoplasty. To investigate the reason for recoarctation, we reviewed the records of 26 infants who underwent subclavian flap repair for symptomatic coarctation of the aorta at less than 3 months of age between June, 1979, and December, 1983. Age at repair ranged from 2 to 65 days (median 16 days) and weight from 2.1 to 4.9 kg (median 3.4 kg). In 14 patients the coarctation was associated with significant intracardiac defects (complex in six). There were two intraoperative deaths and one early death (surgical mortality 12%). The survivors were followed from 6 weeks to 66 months (median 12 months). Five survivors (22%), all operated on at less than 14 days of age, developed severe recoarctation 6 weeks to 6 months (median 5 months) after repair. The obstruction appeared to be due to lumen obliteration by shelf-life posterior wall tissue. Morphometric analysis of preoperative angiograms showed no correlation between recoarctation and (1) distance between the left subclavian artery and the site of coarctation, (2) length of the isthmus, (3) diameter of the isthmus, (4) combined cross-sectional area of the left subclavian artery and isthmus, or (5) the ratio of the combined cross-sectional area of the left subclavian artery and isthmus to the cross-sectional area of the descending thoracic aorta. Recoarctation did not correlate with weight at operation, but it correlated significantly with age at aortoplasty (p = 0.02). The results suggest that intrinsic abnormalities of the periductal aortic wall are responsible for recoarctation after subclavian flap aortoplasty. Particular attention to this abnormal tissue at repair may prevent early recurrence in young infants.

Summary The Abbe flap has been described as a primary procedure for the correction of bilateral clefts of the lip associated with considerable agenesis of tissue. The procedure is a logical application of the principles of plastic surgery to the closure of a large defect where there is inadequate local tissue. Hitherto, closure even of the widest clefts has been achieved by drawing together local tissues under tension. Despite ingenious techniques a taut upper lip and flattened nose are inevitable under such circumstances and require secondary corrective procedures including an Abbe flap. The primary Abbe flap repair is a safe and justifiable operation in such cases.

There are 109 cases of congenital diaphragmatic hernia reviewed. There were 58 survivors in this group. There were 13 recurrences among these 58 cases, an incidence of 22.4%. One can recognize minor and major recurrences. Minor recurrences are usually stable and nonprogressive and, in general, do not require further surgery. The technique of intercostal flap repair of recurrent diaphragmatic hernia is described. This technique has been used in five cases of recurrent diaphragmatic hernia and has proved satisfactory in every instance. It is recommended as the technique of choice in most cases of recurrent diaphragmatic hernia.

Subclavian flap repair in infants with coarctation of the aorta has been shown to be superior to end-to-end reconstruction. Aortic arch coarctations in 2 infants were repaired utilizing reversed subclavian flaps with good results. The effectiveness of flap reconstruction in less common forms of aortic coarctation in infants is demonstrated.

A mycotic aneurysm developed at the site of Dacron patch repair of coarctation in a young adult. The resultant aorto-bronchial fistula was successfully managed by subclavian flap repair.