Single Surgeon Comparison of Midline Versus Overlapping Locoregional Flap Closure Following Spinal Instrumentation.

BACKGROUND: Two techniques for paraspinous muscle flap closure of spine surgeries have been described: one with tension-free mobilization of the muscle flaps approximated at the midline and one with perforators more aggressively dissected to allow for overlapping of the flaps. We seek to compare the surgical outcomes in patients who underwent either type of complex spinal closure as no investigation has yet evaluated a superior technique. METHODS: An institutional review board (IRB)-approved retrospective analysis was conducted on all patients who underwent spine surgery followed by locoregional muscle flap complex closure performed by a single plastic surgeon between January 2016 and July 2021. Patients were divided into 2 groups based on which closure method was employed. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed by multivariable logistic regression with Firth's correction. RESULTS: One hundred and 10 patients with similar baseline demographics were included. There were significantly more smokers (15% vs. 0%, P = 0.02) and a significantly greater rate of postoperative radiation (40% vs. 17%, P = 0.009) in the overlapping group. After controlling for smoking and postoperative radiation, the incidence of surgical site infection, skin necrosis, dehiscence, hematoma, and seroma did not differ between the groups. The procedure length per centimeter of closure was shorter in the midline approximation group, although this data fell just short of significance (3.2 vs. 3.8 minutes/cm, P = 0.08). CONCLUSIONS: The present study demonstrates that both the overlapping and midline approximation of muscle flaps are equally safe and effective strategies for locoregional closure of spinal wounds.

Improved rehabilitation efficiency after cranioplasty in patients with sunken skin flap syndrome: a case series.

PURPOSE: Sunken Skin Flap Syndrome (SSFS) is an uncommon, delayed complication after craniectomy characterized by a functional plateau or decline with variable neurologic symptoms, improving after cranioplasty. SSFS negatively impacts the rehabilitation course, with subjective reports of functional improvement after cranioplasty. However, no studies have assessed the impact of cranioplasty on functional recovery rate. This case series aims to analyze SSFS manifestations and management while awaiting cranioplasty. Also, to assess the role of cranioplasty on rehabilitation outcomes and recovery rate in SSFS patients. METHODS: Four patients were identified with SSFS in inpatient rehabilitation. Each patient had unique clinical manifestations, with multiple strategies used for symptomatic control. Patients spent an average of 23 days in rehabilitation with SSFS symptoms before cranioplasty. After cranioplasty, all patients had SSFS symptom resolution. Comparing change in functional independence measure (FIM) scores and FIM efficiency pre-and post-cranioplasty rehabilitation course, a mean improvement of 23 and 0.72 occurred after cranioplasty, respectively. CONCLUSION: A diagnosis of SSFS should be considered in craniectomy patients exhibiting functional decline or plateau with associated neurological symptoms. This study suggests that FIM and FIM efficiency increases in SSFS patients after cranioplasty, supporting prompt cranioplasty to improve functional outcomes and minimize rehabilitation delays.

New and Recurrent Ulcerations after Free Tissue Transfer with Partial Bony Resection in Chronic Foot Wounds within a Comorbid Population.

BACKGROUND: Chronic foot wounds often require bony resection; however, altering the tripod of the foot carries a risk of new ulcer development nearing 70%. Resulting defects often require free tissue transfer (FTT) reconstruction; outcomes data for various bony resection and FTT options may guide clinical decision-making regarding bone and soft-tissue management. The authors hypothesized that alteration of the bony tripod will increase risk of new lesion development after FTT reconstruction. METHODS: A single-center retrospective cohort analysis of patients undergoing FTT from 2011 through 2019 with bony resection and soft-tissue defects of the foot was performed. Data collected included demographics, comorbidities, wound locations, and FTT characteristics. Primary outcomes were recurrent lesion (RL) and new lesion (NL) development. Multivariate logistic regression and Cox hazards regression were used to produce adjusted odds ratios and hazard ratios. RESULTS: Sixty-four patients (mean age, 55.9 years) who underwent bony resection and FTT were included. Mean Charlson Comorbidity Index was 4.1 (SD 2.0), and median follow-up was 14.6 months (range, 7.5 to 34.6 months). Wounds developed after FTT in 42 (67.1%) (RL, 39.1%; NL, 40.6%). Median time to NL development was 3.7 months (range, 0.47 to 9.1 months). First-metatarsal defect (OR, 4.8; 95% CI, 1.5 to 15.7) and flap with cutaneous component (OR, 0.24; 95% CI, 0.07 to 0.8) increased and decreased odds of NL development, respectively. CONCLUSIONS: First-metatarsal defects significantly increase NL risk after FTT. The majority of ulcerations heal with minor procedures but require long-term follow-up. Soft-tissue reconstruction with FTT achieves success in the short term, but NL and RL occur at high rates in the months to years after initial healing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids: A 13-year experience.

BACKGROUND: Surgical excision combined with radiotherapy is considered an effective treatment for keloids, while the efficacy and safety of this regimen for huge keloids in patients who need reconstruction after excision is still unclear. Therefore, this study aimed to evaluate the efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids in a single center with 13 years of experience. METHODS: All consecutive patients with huge keloids who underwent surgical excision and reconstruction combined with radiotherapy were identified. Demographic information, prior interventions for keloids, parameters and complications, and recurrence rates were documented. RESULTS: Twenty-one patients (10 males; mean age, 43.19 ± 18.15 years) were included, 14 patients reconstructed with z-plasties, 5 with skin grafts, and 2 with skin flaps. During a mean follow-up of 75 months, one patient developed local necrosis without the need for revision surgery and two patients developed temporary hyperpigmentation. Two patients with the z-plasties suffered partial keloids recurrence, which was healed with corticosteroid injection. No wound infection, hematoma, telangiectasia, or new keloids at donor sites were observed. The overall appearance of reconstructed defects was aesthetically acceptable. CONCLUSION: Surgical excision and reconstruction combined with radiotherapy may be safe and effective for huge keloids.

Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study.

OBJECTIVE: To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy. METHODS: Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality. RESULTS: During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts. CONCLUSIONS: Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.

Risk factors and consequences of wound complications following sartorius flap reconstruction.

OBJECTIVE: Groin wound complications are common following vascular surgery and can lead to significant patient morbidity. Sartorius muscle flap coverage may help to prevent vascular graft infection in the setting of wound dehiscence or infection. However, risk factors and consequences of wound complications following sartorius flap reconstruction remain incompletely investigated. METHODS: We retrospectively queried all patients who underwent sartorius flap reconstruction at a tertiary academic medical center. Data collected included patient demographics, medical comorbidities, surgical indication, index vascular procedure, and postoperative outcomes. The primary outcome was wound complication following sartorius flap procedure, which was defined as groin wound infection, dehiscence, or lymphocutaneous fistula. RESULTS: From 2012 to 2022, a total of 113 patients underwent sartorius flap reconstruction. Of these, 66 (58.4%) were performed after the development of a prior groin complication, and 47 (41.6%) were prophylactic. A total of 88 patients (77.9%) had a prosthetic bypass graft adjacent to the flap. Twenty-nine patients (25.7%) suffered a wound complication following sartorius flap reconstruction, including 14 (12.4%) with wound dehiscence, 13 (11.5%) with wound infection, and two (1.8%) with lymphocutaneous fistula. Patients with wound complications had a higher body mass index (28.8 vs 26.4 kg/m2; P =.03) and more frequently active smokers (86.2% vs 66.7%; P = .04). Additionally, patients with wound complications had a higher unplanned 30-day hospital readmission rates (72.4% vs 15.5%; P < .001), reintervention rates (75.9% vs 8.3%; P < .001), and re-do flap reconstruction rates (13.8% vs 2.4%; P = .02). On multivariable analysis, higher body mass index was independently associated with post-flap wound complications (adjusted odds ratio [aOR], 1.01; 95% confidence interval [CI], 1.001-1.03; P = .037). Consequently, wound complications were associated with both surgical reintervention (aOR, 35.4; 95% CI, 9.9-126.3; P < .001) and unplanned hospital readmission (aOR, 17.8; 95% CI, 5.9-54.1; P < .001). CONCLUSIONS: Sartorius flap reconstruction is an effective adjunct in facilitating wound healing of groin wounds. However, wound complications are common following sartorius flap reconstruction and may be associated with reintervention and unplanned hospital readmission. These data support the judicious and thoughtful utilization of sartorius flap procedures among high-risk patients.

Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema.

OBJECTIVE: The aim of the study was to present our experience with the vertical musculocutaneous trapezius (VMCT) flap and highlight its utility in the thoracic wall reconstruction in patients with bronchopleural fistula (BPF). MATERIALS AND METHODS: We present a five case series of patients with long-standing cavities and BPF. The VMCT flap was used, and a direct pathway into the defect was made through a separate posterior thoracotomy shortening the distance between the flap and the defect. RESULTS: In 80% of the cases, the flap succeeded in solving the fistula and filling the defect, quality of life improved, and the need for oxygen decreased. CONCLUSIONS: Management of open window thoracostomy is challenging. Debridement, thoracoplasty, and flap coverage are the mainstream of their treatment, but these patients have scarce available muscle. The VMCT flap represents the major non-affected musculocutaneous unit in the thoracic area after lung surgery. Its dermal component offers a rigid matrix to form a seal over the bronchial stump. Its muscular component adds a good amount of vascularized tissue. No functional impairment has been described after its use.

OBJETIVO: Exponer nuestra experiencia con el colgajo vertical de trapecio y destacar su utilidad en la reconstrucción de la pared torácica en pacientes con fístulas broncopleurales. MATERIAL Y MÉTODOS: Presentamos una serie de cinco pacientes con cavidades y fístulas broncopleurales de larga evolución. Utilizamos el colgajo musculocutáneo vertical de Trapecio, con un redireccionamiento del mismo a través de una ventana costal que permite acortar la distancia entre el colgajo y el defecto. RESULTADOS: La fístula y el defecto fueron solucionados en el 80% de los casos. La calidad de vida mejoró y las necesidades de oxígeno disminuyeron. CONCLUSIONES: El manejo de las toracotomías es un reto. El desbridamiento, toracoplastia y cobertura con colgajo son los pilares de su tratamiento, pero estos pacientes tienen escasa disponibilidad muscular. El colgajo musculocutáneo vertical de Trapecio representa la mayor unidad intacta musculocutánea en el tórax tras cirugía pulmonar. Su componente dérmico ofrece una matriz rígida para sellar el muñón bronquial, su componente muscular añade una gran cantidad de tejido vascularizado. No se han descrito déficits funcionales tras su uso.

Factors Influencing Recurrence in Medial Breast Cancer Tumors After Skin Sparing Mastectomy and Immediate Breast Reconstruction.

BACKGROUND: Skin sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has been established as a safe option for curative-intent surgical resection. Prior studies have shown that medial location of the primary tumor is associated with increased risk of local recurrence. The purpose of this study is to determine the factors associated with recurrence and survival in individuals with breast cancers located in the inner quadrants (medial) who underwent SSM with IBR. METHODS: A retrospective chart review was done on individuals with medial breast cancer who received SSM with IBR in British Columbia between 1980 and 2012. RESULTS: Of 136 individuals with medial breast cancer undergoing SSM with IBR, 27.9% experienced local recurrence and 42.6% overall recurrence. Factors associated with recurrence were T-stage (44.8 vs. 22.4% with T2 disease, P = .02), transverse rectus abdominis muscle (TRAM) flap reconstruction (48.3 vs. 29.5%, P = .00395), prior breast surgery (87.9 vs. 63%, P = .002), and prior radiation therapy (74.1 vs. 38.5%, P < .0001). LR was associated with higher mortality (OR 2.78, 95% CI: 1.26-6.09). CONCLUSION: For patients with medial tumors undergoing SSM with IBR, potential risk factors for recurrence are T-stage, TRAM flap reconstruction, prior breast surgery, and prior radiation therapy. Local recurrence is associated with poor survival.

Effect of microorganisms isolated by preoperative osseous sampling on surgical site infection after autologous cranioplasty: A single-center experience.

PURPOSE: The most frequent postoperative complication in autologous cranioplasty (AC) is infection. European recommendations include osseous sampling before cryogenic storage of a bone flap. We evaluated the clinical impact of this sampling. METHODS: All patients who underwent decompressive craniectomy (DC) and AC in our center between November 2010 and September 2021 were reviewed. The main outcome was the rate of reoperation for infection of the cranioplasty. We evaluated risk factors for bone flap infection, rate of reoperation for any reason (hematoma, skin erosion, cosmetic request, or bone resorption), and radiological evidence of bone flap resorption. RESULTS: A total of 195 patients with a median age of 50 (interquartile range: 38.0-57.0) years underwent DC and AC between 2010 and 2021. Of the 195 bone flaps, 54 (27.7%) had a positive culture, including 48 (88.9%) with Cutibacterium acnes. Of the 14 patients who underwent reoperation for bone flap re-removal for infection, 5 and 9 had positive and negative bacteriological cultures, respectively. Of patients who did not have bone flap infection, 49 and 132 had positive and negative bacteriological cultures, respectively. There were no significant differences between patients with and without positive bacteriological culture of bone flaps in the rates of late bone necrosis and reoperation for bone flap infection. CONCLUSIONS: A positive culture of intraoperative osseous sampling during DC is not associated with a higher risk of re-intervention after AC.

Is There a Risk of Saddle Nose Deformity after Spreader Grafts and Flaps?

Spreader grafts have been used successfully for years to augment the nasal valves among other indications. Spreader flaps have been described as an alternative. However, the literature discussing the complications of these procedures is scarce. This study aims to report and discuss the improvements and complications resulting from using spreader grafts or flaps in a cohort of patients operated upon by the author. Particular stress is given to a group of patients who developed saddle nose deformity after surgery. This cohort included 80 cases of rhinoplasty involving the use of spreader grafts or/and flaps. There was a highly significant improvement in nasal functions postoperatively. Postoperative saddle nose deformity was observed in five patients (6.25%). Spreader grafts/flaps are highly effective in improving nasal functions, but saddle nose deformity appears to be a possible risk. This complication has not been previously reported in the literature in relation to these procedures.

Omental Flap for Complex Sternal Wounds and Mediastinal Infection Following Cardiac Surgery.

INTRODUCTION: Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons. METHODS: Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy. RESULTS: All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful. CONCLUSION: OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.

Multidisciplinary treatment protocol for ischiatic, sacral, trochanteric or other pressure injuries in people with spinal cord injury: a retrospective cohort study.

STUDY DESIGN: Retrospective cohort study Objectives: to describe the incidence and the associated risk factors of post-surgical complications and recurrence in individuals with spinal cord injury/disorder (SCI/D) presenting deep pressure injuries (PIs), treated with a specific surgical and rehabilitation treatment protocol. SETTING: Tertiary Rehabilitation Hospital for SCI/D in Italy. METHODS: Retrospective analysis of the medical records of adult individuals with SCI/D, who developed a PI after the first discharge from a Spinal Unit, underwent flap surgery for PI between July 2011 and January 2018. The statistical unit of analysis was the surgical intervention. Logistic regression analysis with robust standard errors was performed to assess risk factors of post-surgical complications. RESULTS: 434 surgical intervention records were included, for a total of 378 patients. The treated PIs were ischiatic in 56.2% of the cases, sacral in 32.5%, trochanteric in 15.7%, and 5.8% were in other sites. In 239 cases (55.1%) a histological diagnosis of osteomyelitis was confirmed. Minor complications occurred in 13.6% of interventions, while major complications were 3.9%. Sacral PI (OR = 2.55, 95%CI: 1.50-4.35) and muscular/musculocutaneous flap (OR = 2.12, 95%CI: 1.05-4.28) were significant factors associated with risk of post-surgical complications. After a mean follow-up of 21 months (range 12-36), six people (1.4%) had a recurrence. Patients with a recurrence had at least one comorbidity compared to 57% of people without recurrences (p = 0.036). CONCLUSION: Our results demonstrate that complication and recurrence rates can be minimized when an established interdisciplinary and rehabilitation protocol is integrated in the clinical management.

Non-operative adjuncts for the prevention of mastectomy skin flap necrosis: a systematic review and meta-analysis.

BACKGROUND: Native skin flap necrosis is a potentially devastating complication following skin-sparing or nipple-sparing mastectomy with a reported incidence of as high as 30%. Treatment depends on the depth and extent of tissue necrosis and can range from dressings to surgical debridement and further reconstruction. This can have implications on patient physical and psychological wellbeing as well as cost of treatment. This study aims to identify and appraise cost-effective non-surgical adjuncts for the prevention of native skin flap necrosis. METHODS: A systematic review was performed using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement and structured around existing recommended guidelines. A search of MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov was performed with the medical subject headings 'mastectomy' and 'flap necrosis'. After exclusion, 12 articles were selected for review and analysed. RESULTS: A total of 8439 mastectomies were performed on 7895 patients. Preventative non-surgical adjuncts that demonstrated statistically significant reduction in mastectomy flap necrosis included topical nitroglycerin ointment (P = 0.000), closed-Incision negative pressure wound therapy (P = 0.000), topical dimethylsulfoxide ointment (P = 0.03), oral cilostazol (P = 0.032), and local heat pre-conditioning (P = 0.047). CONCLUSIONS: This study identifies multiple adjuncts that may aid in preventing mastectomy skin flap necrosis, especially in high-risk patients. Further studies could aim to define standardized protocols and compare the various adjuncts in different circumstances.

A novel triple dartous fixation in hypospadias repair.

OBJECTIVE: This study investigates the impact of the use of dartos covering to augment the neourethra on functional and cosmetic results. To evaluate a novel technique demonstrating how to fix dartos flap to cover the neourethra as a barrier in hypospadias repair. PATIENTS AND METHODS: This study comprised 204 male patients with different degree of hypospadias (DPH = 132, coronal hypospadias = 46, MPH = 26). Their ages ranged from 1 to 23 ys (mean age = 2 ys). Penile chordee was in (DPH = 45, coronal hypospadias = 33, MPH = 26). All patients had abnormal downward directed urinary stream. Hypospadias repair was performed by the classic TIP technique in addition to our novel modification of dartos covering. Patients were submitted to 5 years of follow-up including clinical examination of the functional and cosmetic parameters. RESULTS: Success rates were reported in 200 patients, 3 patients had complications with subcoronal urethrocutaneous fistula and one patient with complete repair disruption. CONCLUSION: Triple dartos fixation is a simple technique for all hypospadiologists to minimize urethrocutaneous fistula as common complication of hypospadias repair with good functional and cosmetic results.

Comparação de duas técnicas cirúrgicas para recobrimento radicular de recessões unitárias: ensaio clínico paralelo, randomizado e duplo cego / Comparison of two surgical techniques for root coverage of single-unit recessions: parallel, randomized, double-blind clinical trial

As crescentes demandas dos pacientes pelo tratamento das recessões gengivais trazem à tona questões terapêuticas clinicamente significativas, exigindo dos profissionais constante aperfeiçoamento em técnicas cirúrgicas cada vez menos invasivas e mais previsíveis. OBJETIVO: Comparar duas técnicas para recobrimento radicular em recessões gengivais unitárias, unilaterais, do tipo 1. METODOLOGIA: Este estudo clínico, paralelo, randomizado e duplo cego avaliou indivíduos com recessões gengivais unitárias, unilaterais, do tipo 1 (RT1), submetidos à cirurgia para recobrimento radicular, através da associação do enxerto de tecido conjuntivo subepitelial ao retalho posicionado coronalmente (grupo controle) e técnica de túnel (grupo teste). Os principais parâmetros avaliados foram profundidade de sondagem (PS), sangramento à sondagem (SS), nível clínico de inserção (NCI), recessão gengival (RG), faixa e espessura da mucosa ceratinizada (MC e EG), percentual de recobrimento radicular (RR) e fenótipo gengival (FG), além de fatores centrados no paciente (FCP), como dor pós-operatória, hipersensibilidade dentinária cervical (HSDC), estética, grau de satisfação e a qualidade de vida, intra e intergrupo, ao longo de 06 meses de acompanhamento. Os dados foram analisados estatisticamente através dos testes t emparelhado de Student, teste t para amostras independentes, Qui-quadrado, McNemar, Análise de Variância Split-Plot com pós-teste t de Student (α = 5%). RESULTADOS: 46 indivíduos finalizaram este estudo (controle: 23; teste: 23). O tempo de cirurgia foi maior para o grupo teste (controle: 40min ± 5,6; teste: 51min ± 5,9; p = 0,041). Foram observadas reduções estatisticamente significativas para a RG e ganho significativo do NCI, de MC e de EG na análise intragrupo, em ambos os grupos de tratamento, porém, sem diferenças entre as técnicas. O RR aumentou significativamente nos períodos avaliados, mas não foram observadas diferenças intergrupo (controle: 89,2%; teste: 86,5%; p = 0,069). A análise intragrupo revelou mudança de FG (controle: 95,65%; teste: 91,3%; p < 0,001). Ambos os protocolos de tratamento reduziram dor pós-operatória e HSDC, e proporcionaram melhora na estética, satisfação e na qualidade de vida (p < 0,001), sem diferenças entre as técnicas ao longo do tempo. CONCLUSÃO: Ambos os tratamentos apresentaram eficácia clínica semelhante em termos de recobrimento radicular e melhora dos FCP (AU).

The increasing demands of patients for the treatment of gingival recessions bring up clinically significant therapeutic issues, requiring professionals to constantly improve in less invasive and more predictable surgical techniques. AIM: To compare two root coverage techniques to treat single, unilateral, type 1 gingival recessions. METHOD: This parallel, randomized, doubleblind clinical trial evaluated individuals with single, unilateral, type 1 gingival recessions 1 (RT1), who underwent root coverage procedure with subepithelial connective tissue graft associated to a coronally advanced flap (control group) or a tunnel technique (test group). The main parameters evaluated were probing depth (PD), bleeding on probing (BoP), clinical attachment level (CAL), gingival recession (GR), heigth of keratinized tissue (KTH), gingival thickness (GT), percentage of root coverage (RC) and gingival phenotype (GP), in addition to patient-reported outcome measures (PROMs), such as postoperative pain, cervical dentin hypersensitivity (CDH), esthetics, degree of satisfaction and quality of life, intra and intergroup, throughout 06 months follow-up. Data were statistically analyzed using paired Student t-test, t-test for independent samples, Chi-square, McNemar, Split-Plot Analysis of Variance with post hoc t-test (α = 5%). RESULTS: 46 subjects completed this study (control: 23; test: 23). Surgery time was longer for the test group (control: 40min ± 5.6; test: 51min ± 5.9; p = 0.041). Statistically significant reductions for GR and significant gain for CAL, KTH and GT were observed in the intragroup analysis, in both treatment groups, however, without differences between techniques. The CR increased significantly, but no intergroup differences were observed (control: 89.2%; test: 86.5%; p = 0.069). Intragroup analysis revealed a change in GP (control: 95.65%; test: 91.3%; p < 0.001). Both treatment protocols reduced postoperative pain and CDH and improved esthetics, satisfaction and quality of life (p < 0.001), with no differences between the techniques over time. CONCLUSION: Both treatments showed similar clinical efficacy in terms of root coverage and improvement in PROMs (AU).

Colgajo de reposición coronal, con y sin injerto de tejido conectivo, para tratar recesiones gingivales / Coronally repositioned flap with and without connective tissue graft to treat gingival recession

Introducción: Las recesiones gingivales son afecciones de las encías, que son muy frecuentes y podrían provocar repercusiones estéticas, hipersensibilidad dentinaria y tener más tendencia a la formación de lesiones cervicales. Es necesario recubrir la superficie radicular mediante técnicas regenerativas periodontales. Objetivo: Comparar la cantidad de recubrimiento radicular, la profundidad al sondaje y el nivel de inserción clínica, empleando las técnicas de colgajo de reposición coronal, con y sin injerto de tejido conectivo, en pacientes con recesiones gingivales Miller I y II. Métodos: Se incluyeron un total de 16 pacientes con recesiones gingivales Miller clase I y II, de los cuales se seleccionaron 50 piezas dentarias tratadas quirúrgicamente para cubrir las recesiones. Se utilizaron las técnicas de colgajo de reposición coronal, con y sin injerto de tejido conectivo. Las mediciones clínicas fueron comparadas al inicio y a los tres meses posoperatorios. Resultados: Al tercer mes poscirugía los resultados del recubrimiento radicular, profundidad al sondaje y el nivel de inserción clínica para la técnica colgajo de reposición coronal con injerto de tejido conectivo, fueron 0,96 ± 1,33; 0,87 ± 0,63; 1,83 ± 1,7 y para la técnica colgajo de reposición coronal fueron 1,44 ± 1,19; 1,04 ± 0,52; 2,48 ± 1,48, respectivamente. Al comparar el recubrimiento radicular intergrupo no se encontraron diferencias significativas (p = 0,11). Sin embargo, al comparar la profundidad al sondaje intergrupo (p = 0,04), el nivel de inserción clínica intergrupo (p = 0,001) y todas las mediciones clínicas intragrupo (p = 0,001), se encontraron diferencias significativas. Conclusiones: La técnica de colgajo de reposición coronal, con y sin injerto de tejido conectivo, demostró diferencias significativas en la profundidad al sondaje y el nivel de inserción clínica en recesiones gingivales Miller I y II. No se alcanzaron diferencias significativas para el recubrimiento radicular en ambas técnicas a los 3 meses de seguimiento(AU)

Introduction: Gingival recession is a very common gum condition which may result in aesthetic alterations and dentin hypersensitivity, and increase the probability of cervical lesions. It is necessary to cover the root surface using periodontal regeneration techniques. Objective: Compare the amount of root coverage, probing depth and clinical insertion level, using coronally repositioned flap techniques with and without connective tissue graft in patients with Miller I and II gingival recessions. Methods: A total 16 patients with Miller class I and II gingival recessions were included in the study, from whom 50 teeth were selected which had been treated surgically to cover the recessions. The techniques used were coronally repositioned flap with and without connective tissue graft. Clinical measurements were compared at the start of the postoperative period and three months later. Results: Three months after surgery, root coverage, probing depth and clinical insertion level were 0.96 ± 1.33; 0.87 ± 0.63; 1.83 ± 1.7, respectively, for coronally repositioned flap with connective tissue graft, and 1.44 ± 1.19; 1.04 ± 0.52; 2.48 ± 1.48, respectively, for coronally repositioned flap. Root coverage intergroup comparison did not find any significant differences (p = 0.11). However, intergroup comparison of probing depth (p = 0.04) and clinical insertion level (p = 0.001), and all the intragroup clinical measurements (p = 0.001) did find significant differences. Conclusions: Coronally repositioned flap technique with and without connective tissue graft showed significant differences in terms of probing depth and clinical insertion level in Miller I and II gingival recessions. At three months' follow-up, no root coverage significant differences were observed for either technique(AU)

Complex Wound Closure in Adult Spinal Deformity Surgery Reduces Complications in High-Risk Patients.

BACKGROUND: Adult spinal deformity (ASD) surgery is becoming increasingly prevalent. Soft tissue defects arising from revision closure and impaired healing can predispose to wound complications including dehiscence and infection. Soft tissue coverage with local muscle flaps has been shown to minimize wound complications in high-risk patients. In this study we evaluate the role of complex wound closure in preventing wound complications in high-risk spinal deformity patients. METHODS: The authors retrospectively reviewed charts of patients who underwent ASD surgery. Patients were stratified into muscle flap advancement (by neurosurgery or plastic surgery) closure versus primary approximation by neurosurgery. Relevant patient and operative factors were collected and summarized using descriptive statistics. Outcomes of interest included wound complication and revision surgery. RESULTS: Ninety-four cases met inclusion criteria including 56 wounds closed by neurosurgery and 38 wounds closed by plastic surgery (PRS). Of the neurosurgery wounds, 31 and 25 were closed by primary approximation and muscular flap advancement, respectively. Patients operated on by PRS were higher risk than all patients operated on only by neurosurgery (P = 0.0037) but were not significantly higher risk than the neurosurgery performed flap cohort (P = 0.4914). In subgroup analysis, despite similar levels of risk, the PRS population experienced lower rates of any wound complication (P = 0.028) and specifically dehiscence (P = 0.029) compared with the neurosurgery performed flap closure cohort. CONCLUSIONS: Prophylactic involvement of plastic surgery in ASD surgery wound closure may improve wound outcomes in higher risk patients. A multidisciplinary approach with plastic and spine surgeons may lessen the risk of wound complications in high-risk spine surgeries.

Defining Mastectomy Skin Flap Necrosis: A Systematic Review of the Literature and a Call for Standardization.

BACKGROUND: Mastectomy skin flap necrosis following breast reconstruction may lead to wound dehiscence, infection, implant exposure, and reconstructive failure. The absence of a standardized definition for it has led to variation in estimated incidence, from as low as 2 percent to greater than 40 percent. The authors systematically reviewed the literature on mastectomy skin flap necrosis to characterize existing definitions and provide a framework for future classification. METHODS: A systematic review of the PubMed and Cochrane databases identified studies reporting a discrete definition of mastectomy skin flap necrosis and corresponding outcomes in breast reconstruction. Provided definitions were extracted, categorized, and comparatively analyzed. RESULTS: Fifty-nine studies met inclusion criteria, with a combined total of 14,368 patients and 18,920 breasts. Thirty-four studies (57.6 percent) reported mastectomy skin flap necrosis solely as a function of total breasts, and 11 (18.6 percent) reported mastectomy skin flap necrosis solely as a function of total patients. Only 14 studies (23.7 percent) provided two separate rates. The overall rate of mastectomy skin flap necrosis was 10.4 percent (range, 2.3 to 41.2 percent) and 15.3 percent (range, 4.7 to 39.0 percent), when reported per breast or per patient, respectively. Studies were categorized by mastectomy skin flap necrosis definition, including intervention (n = 33), depth (n = 20), area (n = 4), and timing (n = 2). Mastectomy skin flap necrosis rates were highest in studies defining necrosis by depth (15.1 percent), followed by intervention (9.6 percent), timing (6.4 percent), and area (6.3 percent). Necrosis rates among studies defining mastectomy skin flap necrosis by intervention, depth, and area were found to be statistically different (p < 0.001). CONCLUSIONS: Reported mastectomy skin flap necrosis definitions and outcomes vary significantly in the existing literature. For accurate characterization and quantification, a clear, simplified, consensus definition must be adopted.