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Summary Persistent tracheoesophageal fistulas requiring flap repair of the trachea in the mediastinum are uncommon. A 44-year-old man developed a 5 cm x 2 cm persistent posterior tracheal defect after failed tracheo-esophageal fistula repair. The defect was patch repaired using the de-epithelialized skin paddle of an extended pectoralis major flap tunneled into the mediastinum. The use of cross-field ventilation, second rib removal and an anterior tracheostomy slit were crucial for posterior tracheal repair. No major complication occurred. The patch repair with the de-epithelialized skin paddle of pectoralis major flap mucosalized in 2 weeks and the patient was discharged one month postoperatively. The extended skin paddle of the pectoralis major flap was a useful method for tracheal wrap-around reconstruction.

OBJECTIVES A third of infants with congenital diaphragmatic hernia (CDH) require a gastrostomy tube (GT) for nutritional support. We compared CDH infants who are GT-dependent to those able to meet their nutritional needs orally, to identify factors associated with requiring a GT and evaluate their long-term growth. METHODS Patients with CDH repaired at a single institution between 2012 and 2020 were included. Charts were retrospectively reviewed for demographic, surgical, and post-operative details. Mann-Whitney test and Fischer exact test were performed to compare GT-dependent neonates (n = 38, experimental) with orally fed neonates (n = 63, control). Significance was set at

Objectives: To determine the incidence of oronasal fistulas (ONF) associated with primary repair of the anterior palate using a single-layered, superiorly based, vomer mucoperiosteal flap. Design: A systematic review of MEDLINE, PubMed, Cochrane, and Web of Science databases using the keywords: “vomer flap” and “cleft palate repair” were carried out. A meta-analysis was performed using random effect modeling with stratified analysis by syndromic diagnosis, number of surgeons, and mean age. Main Outcome Measure(s): Incidence of ONFs. Results: The meta-analysis included 9 studies with a total of 464 children who met inclusion criteria. The overall ONF rate was 3.0% (95% CI: 1.0-9.0). Fistula rates were not significantly different in studies that included syndromic patients compared to studies that did not, 5.0% (95% CI: 1.0-24.0) versus 3.0% (95% CI: 1.0-6.0), respectively. There was no significant difference between studies in which there was a single surgeon versus multiple surgeons, 3.0% (95% CI: 1.0-13.0) versus 4.0% (95% CI: 1.0-8.0), respectively. Age at the time of cleft repair showed no statistically significant difference in fistula rate when comparing children with a mean age less than 12 months to those greater than 12 months, 3.0% (95% CI: 1.0-5.0) versus 5.0% (95% CI: 1.0-28.0), respectively. Conclusions: The vomer flap technique in cleft palate repair appears to be associated with a low ONF rate unaffected by syndromic diagnosis, number of surgeons, or patient age at time of repair.

BACKGROUND: Little is known about what factors affect patient-reported swallowing outcome after total laryngectomy. We explored whether patient demographics, surgical variables, use of adjuvant treatment, and time since surgery were associated with patient-reported swallowing outcome. \ud \ud METHODS: Cross-sectional study of laryngectomees in eight UK hospitals. Demographic, treatment, and surgical variables were drawn from medical notes. The swallowing outcomes after laryngectomy (SOAL) questionnaire captured perceived swallowing outcome. \ud \ud RESULTS: Two hundred and twenty one participants had complete data on treatment-related variables. In regression analysis, having a free jejunum flap repair and requiring chemoradiation were the only two variables that added significantly to the model of worse self-reported swallowing outcome (R2 adjusted = .23, P

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

Objectives: To observe and analyse the efficacy of retrograde sural neurofasciocutaneous flap repair combined with Jingulian capsules to treat foot and ankle soft tissue defects. Methods: One hundred and eighty patients with foot and ankle soft tissue defects were enrolled in the study from January 2016 to June 2019 in The Second Department of General Surgery, Baoding First Central Hospital. They were divided into a study group and a reference group with the same case number. The former group was provided combination treatment, i.e. retrograde sural neurofasciocutaneous flap repair combined with Jingulian capsules; the latter group was given vacuum sealing drainage. Then, the treatment outcomes of the two groups were compared. Results: The study group needed fewer dressing changes, less preoperative preparation time and antibiotic use than the reference group, p

Introduction/Background* Vulvar and perineal (VP) surgery has to combine surgical efficiency with free margin in an mechanical strained anatomical area with high vulnerability to infectious disease. The size of excision as well as the anatomical restitution strategy justifies simple or complex associated reconstruction techniques.. Methodology All women who underwent VP surgery from November 2014 to August 2020 in our institution were included. The cohort was divided into 3 groups : Groupe 0 (G0) : no reconstruction, Groupe 1 (G1) : fasciocutaneous flap, Groupe 3 (G3) pediculed or perforator flap. Main objective was the margin status specified as follow : Safe Margins (SM) ≥ 8mm, Free Margins (FM) Secondary objective were tumor and excision size, and postoperative morbidity. Data was extract from Excel™ database. Quantitative variables were analyzed using the Chi-square test of Pearson. Result(s)* Twenty-nine consecutive patients (29) were enrolled in the survey : 72,9% invasive disease (main pathological subtype Squamous Cell Carcinoma). Twelve patients had a radical vulvectomy (41,4%) and 10 superficial vulvectomy (34,5%). In group 1, V-Y flap was the most used flap (50%), Lotus Flap in group 2 (58,3%). The others flaps were DIEP, Gracilis, Taylor and rotative flap. Twelve patients achieved SM (41%), 9 patients SM (31%) without any significant difference between the 3 groups (p= 0.68). Among the 8 patients with IM (27%), 6 presented with Paget disease, no patient presented with invasive disease and IM in Group 2. Median size of tumor was similar between the groups (2,5cm vs. 2,8cm, p = 0,76, but excision size seems to be superior in the group 2 (9,5cm vs 6.6cm, p = 0,09). Clavien Dindo Grade 3 complications occurred in 11 cases (37,9%) and grade 2 in 5 cases (17,2%) without significant difference between G1 and G2. Main complication was wound dehiscence (48,3%) and 3 patients had partial flap necrosis. Conclusion* Vulvar and perineal surgery should include the use of a wide range of surgical repair options from local flap to complex reconstruction techniques in order to offer the best compromise between quality of the margins and postoperative morbidity.

Repair for the soft tissue defects of hand has been a major challenge of hand or reconstructive surgery. A lot of flaps are used, free or pedicle flap, but there are no comprehensive description of these flaps. In this article, we retrospectively reviewed the repair technique of the fingertip defect, palmar or dorsal defect of the hand, by using different flaps in 14 cases, between June 2010 and December 2014, and the advantages and limitation of each flap are simply stated. We have shown a lot of surgical pictures, with a small amount of text, providing a wide range of ideas for the surgeon to freely choose an easy and effective method for his own technology. Overall, these approaches are simple, safe, and effective for repairing the soft tissue defect of the hand.

The increasing number of patients with chronic wounds caused by diseases, such as diabetes, malignant tumors, infections, and vasculopathy, has caused severe economic and social burdens. The main clinical treatments for chronic wounds include the systemic use of antibiotics, changing dressings frequently, operative debridement, and flap repair. These routine therapeutic strategies are characterized by a long course of treatment, substantial trauma, and high costs, and fail to produce satisfactory results. Biomaterial dressings targeting the different stages of the pathophysiology of chronic wounds have become an active research topic in recent years. In this review, after providing an overview of the epidemiology of chronic wounds, and the pathophysiological characteristics of chronic wounds, we highlight the functional biomaterials that can enhance chronic wound healing through debridement, anti-infection and antioxidant effects, immunoregulation, angiogenesis, and extracellular matrix remodeling. It is hoped that functional biomaterials will resolve the treatment dilemma for chronic wounds and improve patient quality of life.

The introduction of expanded endonasal approaches to the tumors of the skull base allows for meningiomas to be approached through a transnasal corridor. The resulting defects create high flow cerebrospinal fluid leaks with the need to obtain a durable closure along the anterior skull base, sphenoid planum, or clivus. The nasal septal flap has become the workhorse for endoscopic reconstruction of these defects. This chapter reviews the history, anatomy, and outcomes of the use of the nasal septal flap.

Medial canthal fistulas present a therapeutic challenge, given that the risk factors for development of this and similar complications also contribute to their difficulty to treat. Following surgical, chemotherapy and radiation treatment of a poorly differentiated sinonasal carcinoma, a 61 year old man failed internal and external rotational flap repair and declined further operative procedures; he was satisfied with a novel conservative treatment. This report describes use of Dermaflage®, a silicone-based skin camouflage and topical cutaneous filler product, to both resolve the symptoms of tearing and discharge through the fistula and mask the defect from the casual observer.

Background Lateral sphenoid encephaloceles present a surgical challenge. These encephaloceles may be difficult to access given their lateral location and proximity to the neural and vascular structures of the sphenoid floor, pterygopalatine fossa, and lateral and superior sphenoid walls. Additionally, many patients have idiopathic intracranial hypertension, increasing the risk of recurrence. When untreated or undiscovered, these encephaloceles increase the risk of meningitis. Methods All consecutive endoscopic repairs of lateral sphenoid encephaloceles by a single surgeon from 2012 to 2017 were analyzed for method of repair, complications, and recurrence rate. Odds ratio for recurrence of CSF leak for Alloderm inlay/abdominal fat sphenoid obliteration/nasoseptal flap with multilayer repair vs. other method (Alloderm onlay/contralateral nasoseptal flap or free mucosal graft) was compared, and Fischer’s exact test was used to calculate the two-sided p-value for the two repair methods. Results The success rate (no recurrence of cerebrospinal fluid rhinorrhea) for Alloderm inlay/abdominal fat onlay/nasoseptal flap onlay was 100% while for Alloderm onlay/contralateral nasoseptal flap + free mucosal graft the success rate was 0%. For any nasoseptal flap repair vs. free mucosal graft the success rates were 83.3% and 16.7% respectively. The success rate for Alloderm inlay/abdominal fat onlay/nasoseptal flap onlay vs. Alloderm onlay/contralateral nasoseptal flap + free mucosal graft was statistically significant (p = 0.048), but the success rate for any nasoseptal flap repair vs. free mucosal graft was not significant (p = 0.29). The success rate for patients without post-op lumbar drain vs. with post-op lumbar drain was also nonsignificant (p = 0.29). Conclusions In the author’s hands Alloderm inlay/abdominal fat onlay/nasoseptal flap onlay was superior to other repair methods (Alloderm onlay/contralateral nasoseptal flap or free middle turbinate mucosa onlay graft). The complication rate was low. Post-operative lumbar drainage did not affect the success rate.

IMPORTANCE: Single-center studies have shown that patients report better skin cancer–specific quality of life (QOL) after Mohs micrographic surgery (MMS), but it is unclear whether this improved QOL applies to patients after MMS and complex reconstruction in cosmetically sensitive areas. OBJECTIVE: To evaluate patient QOL after MMS and interpolation flap reconstruction for patients with nasal skin cancers. DESIGN, SETTING AND PARTICIPANTS: This multicenter prospective survey study used the Skin Cancer Index (SCI), a validated, 15-question QOL questionnaire administered at 4 time points: before MMS, 1 week after flap placement, 4 weeks after flap takedown, and 16 weeks after flap takedown. Patients age 18 years or older with a nasal skin cancer who presented for MMS and were anticipated to undergo 2-stage interpolated flap repair by a Mohs surgeon were recruited from August 9, 2018, to February 2, 2020, at 8 outpatient MMS locations across the United States, including both academic centers and private practices. MAIN OUTCOMES AND MEASURES: Mean difference in overall SCI score before MMS vs 16 weeks after flap takedown. RESULTS: A total of 169 patients (92 men [54.4%]; mean [SD] age, 67.7 [11.4] years) were enrolled, with 147 patients (75 men [51.0%]; mean [SD] age, 67.8 [11.7] years) completing SCI surveys both before MMS and 16 weeks after flap takedown. Total SCI scores improved significantly 16 weeks after flap takedown compared with pre-MMS scores, increasing by a mean of 13% (increase of 7.11 points; 95% CI, 5.48-8.76; P

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.

Healing of pilonidal cysts after initial excision remains a vexing problem for surgeons. While simple sinus can be managed with success, recurrence of the cyst after primary excision or sizeable sinus often requires a more complex repair; however, the morbidity and ultimate success of these procedures are unknown. A retrospective review from 2009 to 2014 of all consecutive patients undergoing surgical intervention for pilonidal cyst disease from a single institution was performed. Management of pilonidal disease after excision with flap coverage was examined. Patient demographics, co-morbidities, procedural data, and post-operative outcomes were analyzed. Twenty-one flap patients were identified. These included 15 V-Y fasciocutaneous repairs, 5 rotational flaps, and 1 Romberg flap closure. Mean BMI was 32, mean defect size was 8 cm, and the patients have had an average of 1.05 attempts prior to the excision and flap repair. The flap group demonstrated 14% recurrence rate, 33% reoperation rate, and 47% dehiscence rate. Mean time to healing was 36.4 days. Flap repairs for complex pilonidal cysts have high rates of recurrence, reoperation, and wound dehiscence. However, flap patients represent a more challenging repair with long operative times, blood loss, and large sinus size. Absence of the perfect approach to managing a complex sinus necessitates a thorough description of the problem and a discussion between the surgeon and the patient about the merits of each approach before a decision is made. Level of Evidence: Level IV, therapeutic study.

Skin grafts offer a dynamic repair option for nasal defects of appropriate size, depth, and location. Granulation and grafting can successfully be used as stand-alone reconstructive options or in conjunction with flap repair. This article reviews suitable indications for graft and granulation use in nasal repair to achieve optimum functional and esthetic outcomes.

Transanal advancement flap repair has been considered as a treatment modality for transsphincteric perianal fistulas for over a century. Several systematic reviews have shown that this technique is effective in 80 percent of cases with a minimal and predictable effect on continence. The use of thicker flaps has been shown to increase the rate of recovery, but also to increase the rate of continence impairment. Unfortunately, there are few modifiable factors that seem to affect recovery. These include smoking cessation and weight loss. There is no evidence to support the use of diverting stomas. The placement of setons as part of a standardized treatment regimen is not supported by the literature. It is unadvisable to combine flap repair with other techniques.

Background: Clinical trials have reported that flap repair (FR) can treat anal fistula (AF) effectively. However, no study systematically investigated its efficacy and safety for patients with AF. This study will systematically assess its efficacy and safety of AF. Methods: We will retrieve MEDLINE, EMBASE, Cochrane Library, Elsevier, Springer, Web of Science, Scopus, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Information, and Wanfang Data from their inceptions to May 1, 2019 without any language limitations. The primary outcome is fistula cure rate. The secondary outcomes consist of fistula recurrence rate, fecal continence, quality of life, and complications. RevMan 5.3 software will be used for methodological quality assessment, data synthesis, subgroup analysis and sensitivity analysis. Results: The results of this study will summarize a high-quality synthesis of current evidence for the treatment of FR for patients with AF. Conclusion: The findings of this proposed study will provide evidence for judging whether FR is an effective and safety intervention for AF or not. PROSPERO registration number: PROSPERO CRD42019135507.

One case of epidermal granuloma of the right thumb was diagnosed by color Doppler ultrasonography and pathologic examination. Epidermal granuloma resection and reverse island skin flap transplantation were performed to determine the therapeutic effect of a reverse first dorsal metacarpal artery flap repair of an epidermal granuloma of the right thumb. After effective intravenous combined general anesthesia, the skin in the surgical field was disinfected and sterile drapes were placed. An oblique incision was made over the underlying epidermis granuloma. The right palm of the reverse first dorsal metacarpal artery flap was chosen. The pedicle was carefully protected, and the flap was transplanted to the defective skin area. The incision was sutured after hemostasis. A palpable mass with the dimension of the right thumb of the patient was measured by color Doppler ultrasonography and physical examination pre-operatively. The palpable mass was oval in shape and protruded from the skin surface. The palpable mass had an unclear boundary with the surrounding skin and therefore the skin should be removed. If the tendon is exposed after the resection, complications may occur after operation, such as skin necrosis and tendon exposure. Intra-operatively, the mass was 1.5×1.0 cm in size and multi-cystic. The boundary between the palpable mass and the surrounding skin could not be discerned. The skin area (1.5×1.0 cm in size) was completely invaded by the palpable mass, which was closely adhered to the surrounding tissue. The palpable mass was carefully dissected with appropriate protection to the finger nerves and arteries. The palpable mass and affected skin were completely removed, leaving a defect area of ~1.5 ×1.0 cm without skin. The reverse first dorsal metacarpal artery flap was used to repair the defect area. The repaired flap had a good blood supply and peripheral circulation. The operation was successful, and the anesthesia effect was satisfactory. Treatment of a thumb epidermis granuloma with reverse first dorsal metacarpal artery flap was shown to be a feasible strategy with a broad clinical application.

Objective This study was aimed to compare the closure of skull base defect in endoscopic endonasal transsphenoid surgery of pituitary tumors, using bipedicled nasal septal flap versus fascial closure. The study hypothesis being that bipedicled nasal septal flap is better, compared with fascial closure of skull base defect post–endoscopic endonasal transsphenoid surgery of pituitary tumors. Methods All the eligible patients were randomly divided into two groups and then randomly allocated to the surgeons. In one group, fat and fascia lata was used for closure of the skull base defect and nasal septal flap was not harvested whereas in the other, nasal septal flap was used for closure. Results There was a statistically significant difference in postoperative cerebrospinal fluid leak between the two groups. Patients who had undergone flap repair had lower incidence of postoperative cerebrospinal fluid (CSF) leak. Duration of postoperative hospital stay was also less among the group who underwent flap repair (statistically significant). Conclusion Bipedicled nasal septal flap serves an excellent cover for the skull base defect following endoscopic endonasal transsphenoidal pituitary surgery. It can prevent postoperative CSF leak even in cases where tissue glue is not used.

Introduction: Hypospadias is a common condition which needs to be repaired within the first few years of life. However, the surgery is usually associated with several complications of which Urethrocutaneous Fistula (UCF) is the most common. Several surgical techniques have been described to correct these UCF. Use of a vascularized flap to repair this fistula is the current standard. Aim: To assess the feasibility of using tunica vaginalis flap in repair of UCFs. Materials and Methods: The present study was an observational study where 32 patients with UCF resulting from a previous failed hypospadias repair were subjected to tunica vaginalis flap repair. These patients were followed-up to a mean duration of 18 months to look for recurrence of fistula and other fresh complications. Results: The study included 32 patients of whom 19 had a fistula after primary surgery, 9 had undergone 2 failed surgeries and 4 had undergone 3 previous attempts at hypospadias repair. Majority (29 patients) had a single UCF. No scrotal haematoma or testicular complications were noted. Penile cosmesis was satisfactory as determined by HOSE scoring system. Erection seemed to be unaffected but could be a spurious result as majority of the patients were of pre-pubertal age. After median follow-up of 18 months, two cases had recurrence of fistula; both occurred within 1 month of the surgery. Conclusion: Tunica vaginalis interposition flap repair of urethrocutneous fistula has good outcome.

Extracranial carotid duplex ultrasound is a fast and effective way to study the patency of the extracranial system in most cases. The evaluation of the waveforms of the carotid system can provide valuable clinical information. In this case study, antegrade flow in the left vertebral artery in the absence or occlusion of the left subclavian artery reveals that this is not a subclavian steal case. The normal bi- to triphasic waveform in the left brachial artery, reconstituted with collateral in the thoracic region, supports this argument. The triphasic waveform in the bilateral internal carotid and vertebral arteries correlates with a severe case of congestive heart failure. This case study is a rarely reported extracranial carotid system of a patient status after subclavian flap repair for aortic coarctation in which a portion, if not all, of the subclavian artery has been used as a flap to expand the area of narrowing of the aorta.

The optimal management of the perineal defect following abdominoperineal excision for anorectal malignancy remains a source of debate. The repopularization of extralevator resection means colorectal surgeons are confronted with larger perineal wounds. There are several surgical options available-primary perineal closure and drainage, omentoplasty, biological or synthetic mesh placement, musculocutaneous flap repair, and negative wound pressure therapy. These options are discussed along with the potential benefits and complications of each. There remains no consensus on which management strategy is superior; thus, each case must be tailored for each individual patient. Surgical expertise and availability of a multidisciplinary team approach are important considerations.

Surgery of the lower limb to remove skin cancer often requires the use of skin grafting due to tightness of the surrounding tissues and poor dermal integrity. We present a retrospective case review of our experience with the bridge flap as an alternative for lower leg reconstruction. The techniques of executing this hybrid flap are detailed.

Background Skin texture and color are important considerations during the reconstruction of facial defects, and anatomical borders should be preserved. Therefore, a local flap is a better option. In these cases, the authors repaired facial defects using a bilateral interdigitated V Y flap. Objective We aim to present a modified bilateral Pacman flap technique for the reconstruction of round and oval facial defects. Materials and Methods We performed a retrospective chart review of 25 patients (26 cases) who underwent bilateral interdigitated Pacman flap repair of round and oval facial defects after Mohs surgery for skin cancer from January 2012 to December 2017. The defect sizes ranged from 0.7 to 8.4 cm2 (mean 3.1 cm2). Results All defects were covered successfully and the flaps survived in all cases. One patient had partial flap necrosis that resolved spontaneously. No flap contraction, distortion, or severe scar formation was observed in any patient during the 12-month follow-up period. Conclusion The bilateral interdigitated Pacman flap can cover round and oval facial defects without distortion or central dog-ear deformity. This method is a useful option for facial restoration in selected cases.

To determine the safety and effectiveness of full thickness eyelid reconstructions using a semicircular rotational flap without reconstructing the posterior lamella.The charts of all patients undergoing semicircular flap closure of full thickness eyelid defects by one surgeon (JDP) at the Cole Eye Institute between March 2000 and October 2012 were reviewed. Charts were reviewed for patient demographic information, as well as for the size of the defect, the type of flap used, length of follow-up and complications.Fifty eyelids of 50 patients underwent a semicircular flap repair without posterior lamellar reconstruction during the study period, and 41 charts were available for review. Average patient age was 74 years (range, 40-92 years). Average follow-up was 9.8 months (range, 1-84 months). Average defect size was 19.1 mm (range, 14-30 mm, SD 4.6). Complications included pyogenic granuloma (10 patients, 24.4%), exposure keratopathy (7 patients, 17.1%) lagophthalmos (5 patients, 12.2%), ectropion (6 patients, 14.6%), lateral canthal dystopia (2 cases, 4.9%), eyelid notch (2 cases, 4.9%) and trichiasis (4 cases, 9.8%). Two patients underwent subsequent tarsorrhaphy and one patient underwent ectropion repair. There were no cases of wound dehiscence, diplopia or fornix inadequacy, and the recruited aspect of the eyelid healed well in each case. No case required reconstruction of the eyelid margin or fornix.Semicircular flap repair of full thickness eyelid defects without flap or graft repair of the posterior lamella results in an adequate fornix and a low rate of secondary surgery.

The purpose of this study was to assess primary healing, recurrence and continence after endoanal advancement flap repair (EAFR).Seventy-seven patients with fistulas-in-ano of different etiologies received endoanal advancement flap repair between 1997 and 2009. This is a prospective, non-randomized, single-centre, single-surgeon study.Follow-up data was available for 71 patients. 47.9 % had cryptoglandular fistulas. In 40.8 %, the fistulas were due to chronic inflammatory bowel disease. In 11.3 %, the fistula was a consequence of treatment for cancer. Primary healing was observed in 41 of the cases (57.7 %). The median time to recurrence was 27 months (mean 43.43 ± 48.11) and differed significantly across the patient groups: cryptoglandular origin 51 months (mean 57.09 ± 52.57), condition after cancer treatment 43 months (mean 31 ± 23.142), inflammatory bowel disease 11 months (mean 23.65 ± 32.47) (p 0.01). Preoperatively, 31 (44.3 %) of the patients had impaired continence vs 30 (42.9 %) postoperatively. Overall, postoperative mean Cleveland Clinic incontinence score values improved significantly (preoperative 3.74 ± 4.558 vs postoperative 2.68 ± 4.752, p = 0.03).Full-thickness endoanal advancement flap repair is a successful treatment option for a range of fistula etiologies. Overall, fistula aetiology proved to be prognostically more relevant than fistula location. Fistulas associated with chronic inflammatory bowel disease were found to have a significantly higher rate of recurrence and shorter time to recurrence at long-term follow-up. Repeat interventions do not negatively impact postoperative continence.

Objective: We have utilized subclavian flap angioplasty (SFA) frequently in infants with coarctation particularly in patients with arch hypoplasia which is quite frequent. We have followed these patients with serial echocardiography and have analyzed our results in this study to determine recoartation rates, recurrent hypertension and left arm development. Methods: Thirty eight infants less than 3 months age (22 boys and 16 girls, mean age was 28±22.6 days) operated at Dokuz Eylul University Hospital between August 2007 - December 2013. Twelve (32%) patients with pulmonary banding due to accompanying VSD or AVSD were included to the study, those infants with complex pathologies such as transposition of great arteries or single ventricle, while the patients less than 1000 gram in weight were excluded. Results: The mean follow-up time was 21 months (1-76 months). Twelve (32%) patients had aortic arch hypoplasia proximal to the left subclavian artery. Operative mortality was found 7.7% for isolated coarctation, 16% for coarctation repair with pulmonary banding. In 5 patients, a residual gradient was detected and re intervention was required in 7.8% patients with balloon angioplasty. Conclusion: Subclavian flap angioplasty is a safe repair technique in small infants and neonates. High gradients and intervention more likely depends on the anatomy of the aortic arch rather than the subclavian flap angioplasty technique.

Cervical esophageal perforation is a rare and life-threatening condition. Its prompt diagnosis and treatment require a high index of suspicion. Cervical spine hardware is an uncommon cause of posterior esophageal perforation. Management has included a variety of musculofascial flaps for surgical repair. We present 2 cases of cervical esophageal perforation induced by spinal hardware that were repaired with a superior omohyoid muscle (SOM) flap for closure and/or primary closure reinforcement. Advantages and techniques of the SOM flap are discussed.

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.

This report highlights an unusual case of an atypical melanocytic proliferation in a pediatric patient and the surgical method used to repair the defect. I describe a 10-year-old boy with hallux irregular discoloration that was present from birth and rapidly enlarging. A biopsy led to the diagnosis of atypical melanocytic proliferation, which may represent an unusual manifestation of early melanoma in situ. Complete excision of the patch was performed, and the hallux was repaired using a double advancement flap for closure, thus curing the patient.

Summary Background Due to the relative lack of a mobile tissue reservoir, the flap repair of large defects of the temple and lateral forehead is challenging. Objective To present our experience of the contralateral subgaleal sliding (CLASS) flap for the single-stage aesthetic repair of such defects. Methods Data were collated on all patients at one regional Mohs centre in whom the CLASS flap had been performed since 2011. Results The CLASS flap was performed on 16 patients (11 male, five female) with an average age of 63 years (range 42–90). The average defect size was 2·8 × 3·1 cm. A single case of postoperative infection occurred, which settled with appropriate therapy with no adverse sequelae. All patients rated their outcome as good or excellent. Conclusion The CLASS flap is a reliable, aesthetic, single-stage reconstructive technique for large defects of the lateral forehead and temple.

Hard palate closure with a vomer flap at the time of lip repair has been widely adopted. A recent study by Deshpande et al. showed a high rate of failure of the vomer flap and led the authors to abandon the technique. We conducted a retrospective study of vomer flap healing in a consecutive series of cases performed by the senior author (D.O.). The case records of 71 patients who underwent repair of unilateral cleft lip and palate with a vomer flap at the time of lip repair were studied. Vomer flap healing was assessed and documented by the senior author at the time of definitive palate closure, and this was recorded. Adequate records were available for 66 cases. Twelve patients (18%) had associated syndromes and were included in the analysis. The median age at the time of lip and vomer flap repair was 3.5 months, and that at the time of palate repair was 8 months. At definitive palatoplasty, the vomer flap was intact in 62 patients (94%). Four patients (6%) had partial or complete failure of the vomer flap. All failures occurred in cases where the vomer flap was sutured directly to the nasal mucosa, a technique since abandoned in favour of double-breasting the flap to the raw surface of the oral mucosa. Five patients had incomplete healing of the palate following definitive palatoplasty, two of whom had a previous vomer flap failure. Contrary to Deshpande et al., we found the vomer flap to be highly reliable in closing the hard palate at the time of primary lip repair.

Vomer flap repair is assumed to improve maxillary growth because of reduced scarring in growth-sensitive areas of the palate. Our aim was to evaluate whether facial growth in patients with unilateral cleft lip and palate was significantly affected by the technique of hard palate repair (vomer flap versus two-flap).For this retrospective longitudinal study, we analyzed 334 cephalometric radiographs from 95 patients with nonsyndromic complete unilateral cleft lip and palate who underwent hard palate repair by two different techniques (vomer flap versus two-flap). Clinical notes were reviewed to record treatment histories. Cephalometry was used to determine facial morphology and growth rate. The associations among facial morphology at age 20, facial growth rate, and technique of hard palate repair were assessed using generalized estimating equation analysis.The hard palate repair technique significantly influenced protrusion of the maxilla (SNA: β = -3.5°, 95 % CI = -5.2-1.7; p = 0.001) and the anteroposterior jaw relation (ANB: β = -4.2°, 95 % CI = -6.4-1.9; p = 0.001; Wits: β = -5.7 mm, 95 % CI = -9.6-1.2; p = 0.01) at age 20, and their growth rates (SNA p = 0.001, ANB p 0.01, and Wits p = 0.02).The results suggest that in patients with unilateral cleft lip and palate, vomer flap repair has a smaller adverse effect than two-flap on growth of the maxilla. This effect on maxillary growth is on the anteroposterior development of the alveolar maxilla and is progressive with age. We now perform hard palate closure with vomer flap followed by soft palate closure using Furlow palatoplasty.These findings may improve treatment outcome by modifying the treatment protocol for patients with unilateral cleft lip and palate.

Background: Coarctation is a congenital narrowing of the aorta that often requires repair during infancy. The subclavian flap aortoplasty was once widely favored for its avoidance of a circumferential suture line and low incidence of recoarctation. The aim of this study is to report the long-term results of the subclavian flap repair for coarctation of the aorta in infants. Methods: Our operative database was queried for infants with coarctation who underwent subclavian flap aortoplasty from 1966 to 1991. Medical records were reviewed for patient characteristics and outcomes. Survivors were identified for additional phone interview. Results: Fifty-five patients met the inclusion criteria. There were 7 early deaths (in hospital), 11 late deaths, 5 patients lost to follow-up, and 32 known long-term survivors with a mean follow-up of 22.0 years (range 2.4-34.9). Hospital mortality was not associated with patient characteristics but was associated with earlier year of surgery ( P = .015). A trend toward decreased overall survival was seen in patients with coarctation with associated cardiac defects ( P = .072). Reintervention for recoarctation was required in 3 (6.6%) patients and was not related to the patient characteristics. There were no apparent complications related to subclavian artery sacrifice. Conclusions: Subclavian flap aortoplasty provides excellent long-term results for the repair of coarctation in infants. The incidence of recoarctation requiring reintervention is low and compares favorably with other techniques. Compromise of growth or function of the left arm was not appreciated. The subclavian flap technique remains a viable surgical option for the repair of coarctation in infants.

Several biomaterials have been proposed to treat anal fistula alone or in combination with other surgical procedures aiming to reduce recurrence rates while minimizing continence impairment. More recently a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulae. We propose an approach consisting of non-cutting seton positioning followed several weeks later by flap repair associated with dermal matrix injection into the fistula tracts. We report our experience with this two-staged procedure on 24 consecutive patients with complex anal fistulae with a median follow up of > 12 months. In our experience this two-stage approach seems to be safe and effective.

Background The aim of the study was to test the hypothesis that in patients with chronic complex sternum dehiscence, the use of muscle flap repair minimizes the occurrence of paradoxical motion of the chest wall (CWPM) when compared to sternal rewiring, eventually leading to better respiratory function and clinical outcomes during follow-up. Methods In a propensity score matching analysis, out of 94 patients who underwent sternal reconstruction, 20 patients were selected: 10 patients underwent sternal reconstruction with bilateral pectoralis muscle flaps (group 1) and 10 underwent sternal rewiring (group 2). Eligibility criteria included the presence of hemisternum diastases associated with multiple (≥3) bone fractures and radiologic evidence of synchronous chest wall motion (CWSM). We compared radiologically assessed (volumetric computed tomography) ventilatory mechanic indices such as single lung and global vital capacity (VC), diaphragm excursion, synchronous and paradoxical chest wall motion. Results Follow-up was 100% complete (mean 85±24 months). CWPM was inversely correlated with single lung VC (Spearman R=-0.72, p=0.0003), global VC (R=-0.51, p=0.02) and diaphragm excursion (R=-0.80, p=0.0003), whereas it proved directly correlated with dyspnea grade (Spearman R=0.51, p=0.02) and pain (R=0.59, p=0.005). Mean CWPM and single lung VC were both better in group 1, whereas there was no difference in CWSM, diaphragm excursion and global VC. Conclusion Our study suggests that in patients with complex chronic sternal dehiscence, pectoralis muscle flap reconstruction guarantees lower CWPM and greater single-lung VC when compared with sternal rewiring and it is associated with better clinical outcomes with less pain and dyspnea.

Objectives: We evaluated the lateral crural J-flap technique in the surgical repair of external nasal valve collapse with standardized and validated outcome measurements. Methods: Prospective data were gathered on consecutive cases, performed by a single surgeon between 2007 and 2010, of adult patients who underwent a lateral crural approach to repair of external nasal valve collapse. Data were collected on diagnosis, surgical outcomes, and complications. Outcome measures included the Nasal Obstructive Symptom Evaluation and the Rhinoplasty Outcome Evaluation. Results: Fifteen patients were included in the study. Their follow-ups ranged from 9 to 13 months. All patients had statistically significant improvements in Nasal Obstructive Symptom Evaluation scores. There was no significant change in perceived nasal appearance after surgery as measured by the Rhinoplasty Outcome Evaluation. There were no surgical complications. Conclusions: The lateral crural J-flap approach to repair of external nasal valve collapse is a technically straightforward and relatively safe procedure. The efficacy is excellent at the 1-year follow-up examination.

Rectal advancement flap is a popular option for treatment of complex anal fistula. Although early outcomes vary, concerns remain about postoperative continence, long-term healing, and its role in patients with Crohn's disease and anovaginal fistulas.This study aimed to report long-term outcomes in patients with complex fistula disease.Patients who were undergoing rectal advancement flap for anal fistula were included in the study.Patients were contacted to determine the status of their fistula disease, their bowel function, and their degree of fecal incontinence.The main outcomes measured were healing rate and continence.There were 98 patients, 43 men and 55 women, mean age 53 ± 14 years. Fifty-eight had cryptoglandular fistulas, and 40 (41%) had IBD (33 had Crohn's disease). Seventy-seven of 98 patients had perianal fistulas, and all 77 underwent seton drainage before advancement flap. Twenty-one women had anovaginal fistulas. Average postoperative length of stay was 3 ± 1 days. There were no mortalities. Follow-up was possible in 75 patients, a mean of 7 ± 3 years after surgery. Primary healing occurred in 54 (72%) patients. Twenty-one patients (28%) underwent further treatment, and 12 (57%) healed after a second advancement flap. Four more patients healed after more than 2 flaps or fistulotomy leading to an overall healing rate of 70 of 75 (93%). Patients with Crohn's disease had lower healing rates than those with cryptoglandular fistulas (87% vs 98%). Thirty-two patients (43%) had normal fecal continence before flap, and 43 (57%) had normal fecal continence after flap.Advancement flap is a good option for patients with complex anal fistulas.

Hypospadias is a developmental halt of the genital tubercle which seems to be on the increase. Even though there is no universal technique for repair of hypospadias and each surgeon has his own convictions, sometime quiet wrong. There was a significant disparity of opinion between patients and surgeons about the cosmetic outcome. No direct comparison has been attempted between the Snodgrass repair and other established techniques and so we evaluated it with Preputial Island Flap repair in distal penile hypospadias in respect to post operative fistula. We took total of 40 patients of 3-8 years of age and divided 20 patients in each group. 45% cases of Snodgrass repair had a fistula while 20% of the patients underwent preputial island flap

The use of biomaterials to treat anal fistula has drawn great interest. More recently, a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulas.We propose a novel approach consisting in non-cutting seton positioning followed by flap repair associated with dermal matrix injection into the fistula tracts after several weeks.We report our experience with this two-staged procedure on 11 consecutive patients with recurrent high trans-sphincteric fistulas with a minimum follow-up of 6 months.In our experience, this two-stage approach seems to be safe and effective.