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Objectives: The aim of this systematic review was to assess the effectiveness of the available techniques for the management of peri-implant soft tissue defects around single implants in the anterior region., Material and Methods: A comprehensive search was conducted in PubMed (MEDLINE), Web of Science (all databases), and Cochrane, using keywords and MeSH terms related to the topic. This systematic review included prospective interventional studies with a minimum of 10 patients and at least 6 months of follow-up., Results: A total of 13 articles were included, with eight focusing on outcomes related to buccal soft tissue dehiscence coverage procedures and the remaining five investigating interventions aimed at augmenting soft tissue thickness. Coronally advanced flap in combination with connective tissue graft was the most effective technique for buccal soft tissue dehiscence coverage in the medium and long term. In terms of increasing soft tissue thickness, both connective tissue graft and acellular dermal matrix demonstrated satisfactory short-term outcomes; however, their long-term efficacy remains unclear., Conclusions: Soft tissue augmentation procedures resulted in satisfactory outcomes, in terms of buccal soft tissue dehiscence coverage and soft tissue thickness increase, around single implants in the esthetic area. Peri-implant plastic surgery has improved both the esthetic appearance and quality of life of patients., Prospero Registration Code: CRD42023398424., (© 2024 The Author(s). Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.)

Background: The tunnel technique (TUN) preserves the integrity of the papilla by creating envelope flaps that allow for the insertion of a connective tissue graft, and/or biomaterials., Methods: (1) A comprehensive overview of tunneling flap procedures in the treatment of gingival recessions (GRs) for soft tissue coverage is presented and (2) A classification system for soft and hard tissue anatomy of GR sites which may aid the clinician in determining the surgical complexity is being introduced., Results: A novel clinical classification system is proposed to illustrate complexity levels determined by soft and hard tissue anatomy of GR sites such as the mucogingival junction proximity to the gingival margin, bone morphotype, and mucosal margin thickness., Conclusions: TUN is highly effective in treating single/multiple GRs. Its limitations are related to variability in surgical site anatomy and operator expertise. A classification system based on anatomical soft and hard tissue variations has been proposed to help identify complexity levels encountered during tunneling procedures., Key Points: Site-related factors directly impact the surgical variables related to tissue trauma, flap tension, soft tissue management, muscle pull, and wound stability during the healing of gingival recessions (GRs). The achievement of expedited and favorable wound healing is crucial to obtaining quantitative and qualitative success in the treatment of GR and the long-term stability of root coverage. A classification system based on anatomical soft and hard tissue variations has been proposed to facilitate tunneling procedures while respecting surgical principles., (© 2023 American Academy of Periodontology.)

Purpose: This study aimed to investigate the biomechanical properties, cell migration, and revascularization of the acellular dermal matrix Epiflex. As a decellularized, freeze-dried human skin graft, Epiflex has broad applications in medical fields, particularly in implantology and dentistry. Understanding its biomechanical characteristics is crucial for its clinical adoption as a novel soft tissue graft option., Methods: Epiflex (n = 3) was evaluated in comparison to palatal tissue from body donors (n = 3). Key metrics, such as elongation and tear resistance, were quantified. Both graft types underwent histological analysis and scanning electron microscopy. Additionally, the healing properties of Epiflex were assessed using a Chorioallantoic Membrane (CAM) Assay., Results: Biomechanically, Epiflex (mean = 116.01 N) demonstrated the ability to withstand greater forces (p = 0.013) than human palatal tissue (mean = 12.58 N). When comparing the elongation, no significant difference was measured (ASG mean = 9.93 mm, EF mean = 9.7 mm). Histologically, Epiflex exhibited a loosely connected network of collagen fibers with a dense upper layer. The CAM Assay indicated efficient revascularization., Conclusion: Epiflex appears to be a viable option for soft tissue augmentation, particularly appealing to patient groups who avoid all or specific animal-derived products due to ethical or religious reasons., (© 2024. The Author(s).)

The biggest challenge during periodontal regeneration in the anterior region is the prevention of soft tissue recession. Minimally invasive surgeries, particularly papilla preservation techniques and soft tissue augmentation, may significantly reduce such postoperative soft tissue recession. This article presents the vestibular incision subperiosteal tunnel access (VISTA) approach for periodontal regeneration in the anterior region. A subperiosteal tunnel prepared from a single vertical vestibular incision adjacent to the defect is used for debridement, application of enamel matrix derivative, defect grafting with corticocancellous tuberosity bone, and insertion of the connective tissue graft. Evaluation of six cases with up to 6 years of follow-up showed improvements in all clinical parameters. The probing pocket depth improved from 8.2 ± 0.75 mm initially to 2.7 ± 0.52 mm at follow-up, clinical attachment level improved from 8.5 ± 0.83 mm initially to 2.7 ± 0.52 mm at follow-up, and midfacial gingival recession of 1 mm at two sites was corrected. The papillae were stable at all sites, with an average distance of 4.8 mm from the incisal edge to the papilla tip. This technique seems to be a promising approach for achieving both esthetic and functional goals of periodontal regenerative surgery. However, experience in performing microsurgeries and harvesting tuberosity tissues may be a limitation.

Objectives: Open surgical repair (OSR) of descending and thoracoabdominal aortic aneurysms carries risks of mortality and major complications. Patients with connective tissue disorders (CTD) are younger and require safe, efficient treatment with long-term durability. This study provides current outcome data to help inform treatment decisions., Methods: All OSRs of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) from January 2011 to July 2021 were included in a retrospective cohort study. Primary outcome measures were early and follow-up mortality and reintervention. Secondary outcome measures were major complications. Kaplan-Meier methods were used to estimate reintervention-free survival., Results: A total of 26 OSRs (7 DTAA, 19 TAAA) were performed in 23 patients: 20 (77%) Marfan and 6 (23%) Loeys-Dietz syndrome; median age 43 years. Aortic dissection was present in 100% and 3/26 (12%) were urgent. Early mortality was 1/26 (3.8%). No patient suffered spinal cord ischemia, stroke, vocal cord paralysis, or re-exploration for bleeding. The transient respiratory failure occurred in 19% (5/26) and transient renal replacement therapy in 15% (4/26). Renal function normalized in all patients within 3 months. During follow-up (median 4.6, range 0-11 years) there were no deaths and only one re-intervention on a previously operated aortic segment, resulting in 92% reintervention-free survival at 5 years., Conclusions: In dedicated units, open surgical DTAA and TAAA repair in patients with CTD can be performed with a very low risk of death, severe complications and, late re-intervention. For CTD patients with reasonable risk, OSR should remain the first line of treatment.

Background: Data on the efficacy of endovascular thoracic endovascular aneurysm repair (TEVAR) versus open surgical repair for chronic aortic pathology in patients with connective tissue disorders are limited. In particular, few studies have examined outcomes of TEVAR versus open repair for intact descending thoracic aortic aneurysms (DTAA) in this subset of patients beyond index hospitalization. Therefore, we investigate 5-year outcomes of TEVAR and open surgical repair of intact DTAAs in patients with known connective tissue disorders., Methods: Using the TriNetX Data Network, a global federated database of over 75 million patients, we conducted a retrospective cohort study of patients with connective tissue disorders and intact DTAAs, treated initially with either TEVAR or open surgery. Eligible patients were 1:1 propensity score-matched for several preoperative co-variates including demographics, surgical history, and comorbidities. We calculated and compared 5-year cumulative incidence and hazards of death, re-intervention, aortic dissection, renal failure, stroke, intracranial hemorrhage, paraplegia, and limb ischemia using the Kaplan-Meier method and Cox proportional hazards models., Results: We identified 55 patients treated with TEVAR and 200 treated with open surgery. After matching, we compared 46 patients in each cohort. After matching, only incidence of re-intervention via endovascular approach was significantly higher among patients in the TEVAR cohort (27.1% vs. 4.8%, P = 0.009). Rates and hazards of other outcomes were higher in the TEVAR group, however, differences were not statistically significant., Conclusions: Patients treated with TEVAR had numerically higher rates of adverse outcomes compared to open surgical patients, however only the difference in re-intervention rate was statistically significant. Given the evolving landscape of endovascular intervention, greater-powered studies are needed to determine the safety and efficacy of TEVAR for intact DTAAs in a select subset of connective tissue disorder patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Prominent ear deformity occurs in 5% of the general population and has been treated by otoplasty for many years to address the psychosocial challenges of having such a deformity. There is extensive literature but no consensus on the best method to address potential surgical complications, including suture extrusion., Objectives: The aim of this article was to describe a surgical technique designed to reduce suture extrusion following otoplasty surgery by placing free soft tissue grafts between Mustardé sutures and postauricular skin., Methods: Two hundred and eleven patients who underwent otoplasties with soft tissue grafts between January 2017 and January 2020 were included in this study. All surgeries were performed by 2 facial plastic surgeons with more than 20 years of experience each, practicing in Toronto, Canada. Patients were followed up to assess for suture extrusion between 12 and 36 months (median, 21 months) postoperatively. The rates of suture complications and extrusion were compared with those previously reported in the literature., Results: Only 2 patients out of 211 (0.47%) had unilateral suture extrusion and were treated with suture removal. This is dramatically lower than the upper values reported in the literature, which average 5.55% (range, 0%-22.2%)., Conclusions: A soft tissue graft separating the Mustardé sutures and postauricular skin acts as a barrier, and can be used in conjunction with traditional surgical techniques. By adding this graft in the proposed manner, there is additional tissue reinforcing the suture repair, thereby reducing the rates of suture complications and extrusion without increasing the operative time., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Mandibular anterior teeth are most frequently affected by gingival recession. However, data regarding mucogingival treatment aimed at root coverage in this specific location are limited., Objective: The purpose of this study was to systematically review the scientific literature and to use the meta-analytic approach to address the following focused question: "What is the effectiveness of different surgical approaches on clinical and patient-related outcomes in the treatment of buccal gingival recessions on mandibular anterior teeth?", Methods: Studies were located by searching 3 electronic databases (Medline, Scopus, and Cochrane databases) and cross-referencing. Randomized and nonrandomized studies including at least 1 arm involving the use of pedicle flaps and/or free soft tissue grafts in the treatment of gingival recessions (recession type [RT] 1 and RT2) located on the buccal aspects of mandibular centrals, laterals and canines, were included in the analysis. Primary outcome was mean root coverage (mRC), expressed in percentage, based on a 3- to 12-mo follow-up observation. A Bayesian single-arm network meta-analysis was performed to identify a treatment hierarchy of the different surgical techniques., Results: Sixteen studies, with a total of 23 arms, were included in the quantitative analysis. The greatest mRC is associated with laterally positioned flap (LPF) + connective tissue graft (CTG) (91.2%) and tunnel (TUN) + CTG (89.4%), whereas LPF alone, coronally advanced flap (CAF) + CTG, and free gingival graft (FGG) showed lower mRC (79.1%, 78.9%, and 68.5% respectively). TUN + CTG provides significantly greater mRC compared to CAF+CTG. No difference among the procedures could be observed in terms of keratinized tissue width gain., Conclusions: Treatment hierarchy generated by an arm-based network meta-analysis model suggested that tunnel and laterally positioned flap, both in combination with connective tissue graft, may provide the greatest mean root coverage in the treatment of mandibular anterior recessions., Knowledge Transfer Statement: The results of the present systematic review can be used by clinicians when deciding which approach to adopt when treating buccal gingival recessions on mandibular anterior teeth. In particular, procedures based on a laterally positioned flap or a tunneling technique, both in combination with connective tissue graft, seem to be the most predictable therapeutic decision.

Combined surgical procedures have been introduced that combine periodontal regenerative/reconstructive procedures in intrabony defects with a connective tissue graft to compensate for a deficient bone wall and limit soft tissue shrinkage, but little is known about the reproducibility of these advanced surgical techniques. This 12-case series applies a combined surgical procedure, combining amelogenins, bone substitutes, and connective tissue graft to treat deep intrabony defects associated with gingival recession. Twelve deep intrabony defects with a mean clinical attachment loss of 9.9 ± 2.1 mm, mean probing depth (PPD) of 7.8 ± 1.5 mm, mean recession of the tip of the interdental papilla (TP) of 2.1 ± 1.5 mm, and mean buccal recession (REC) of 2.3 ± 1.8 mm were treated. At 1 year, the average attachment gain was 5.1 ± 1.8 mm (P < .001), the residual PPD was 2.9 ± 0.7 mm (P < .001), no change was observed in the TP (-0.4 ± 0.8 mm, P = .078), and the REC slightly decreased to 1.7 ± 1.5 mm (P = .047). These results suggest that the proposed technique led to predictable clinical outcomes that support regeneration while maintaining or improving the position of the soft tissue margin for the interdental and buccal aspects in deep intrabony defects associated with gingival recession.

Purpose: To evaluate the influence of connective tissue graft on the soft tissue thickness and aesthetics around single implants placed in the aesthetic zone of the maxilla., Materials and Methods: Forty-two patients with indications for single implant placement in the aesthetic zone were randomly allocated into two groups: the implant group (implant insertion) and the implant + connective tissue graft group (implant insertion and placement of a 1.50-mm-thick connective tissue graft). Clinical evaluations were performed at baseline, 4 months after surgery (prior to prosthetic reconstruction) and 1 year after crown placement to assess tissue thickness at the crestal aspect and the buccal aspect, buccal defects, keratinised tissue width and proximal bone resorption. Aesthetics were assessed using the pink aesthetic score index, and postoperative discomfort and pain tests were also performed., Results: Only the implant + connective tissue graft group presented a significant increase in tissue thickness at the buccal aspect, with 2.36 ± 0.94 mm at baseline, 3.35 ± 1.00 mm after 4 months and 3.23 ± 0.77 mm after 1 year (P < 0.05), whereas no change was observed in the implant group. The difference between the two groups was significant after 4 months and 1 year (P < 0.05). The implant + connective tissue graft group also showed a greater reduction in buccal defects after 1 year compared to the implant group (∆ -0.50 ± 0.70 mm and ∆ -1.80 ± 1.30 mm, respectively; P < 0.05). After 1 year, a significant intergroup difference in proximal bone resorption was observed, with the implant + connective tissue graft group showing less bone resorption compared to the implant group (0.75 ± 0.20 mm and 0.92 ± 0.30 mm, respectively; P < 0.05)., Conclusions: Placement of a connective tissue graft simultaneous to single implant insertion in the anterior maxillary region can increase the thickness of the peri-implant mucosa and reduce proximal bone resorption.

Objectives: This study was conducted to compare the healing response of localized gingival recession defects treated with a coronally advanced flap (CAF) and either an amnion allograft membrane (AM) or a connective tissue graft (CTG)., Methods: Gingival recession defects were surgically created in six healthy mongrel dogs at the labial root surface of the maxillary canines, bilaterally. Using a split mouth design, the defects were treated with CAF and either AM (CAF/AM) or CTG (CAF/CTG). Three animals for each group were scarified at 1 and 3 months. Segments containing the defects were prepared for histological and histometric analysis., Results: Both techniques showed similar clinical findings with adequate root coverage. Histologically, healing was characterized by the formation of new cementum and new connective tissue attachment in the CAF/AM group; in the CAF/CTG group, healing was characterized by junctional epithelium, coronally, and connective tissue fibers parallel to the root surface, apically. Histometrically, the CAF/AM group revealed a substantially shorter epithelial length and a longer, new cementum compared with those of the CAF/CTG group after a healing period of 3 months., Conclusions: Within the limits of this study, we concluded that the AM allograft could promote periodontal healing in gingival recession defects., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2022 Japanese Association for Oral Biology. Published by Elsevier B.V. All rights reserved.)

Connective tissue disorders represent a varied spectrum of syndromes that have important implications for the spine deformity surgeon. Spine surgeons must be aware of these diverse and global manifestations of disease because they have significant impact on perioperative and postoperative outcomes., Competing Interests: Disclosure The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article. None of the authors received financial support for this manuscript., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: The mandibular anterior lingual (MAL) keratinized tissue (KT) band is often insufficient in dimension: <2 mm height of which <1 mm is attached gingiva (AG). Its gingival phenotype is commonly characterized as thin (<1 mm) gingival thickness (GT) and having inadequate (<1 mm) AG width. When surgical treatment is indicated, prevention of significant apical displacement of the gingival margin and improvement of long-term gingival stability are enhanced by KT increase and phenotype modification in order to establish thick GT and adequate AG. The aim of this case report is to describe a bilaminar surgical approach, the modified coronally advanced flap (mCAF) and connective tissue graft with retained KT band (mCAF + CTGkt). It is an outcomes-driven surgical approach for KT increase and phenotype modification in order to predictably establish thick GT and adequate AG. The mCAF + CTGkt procedure is minimally invasive, predictable, well-tolerated and addresses both the unique features of MAL anatomy and normal oral functioning movement during the postoperative healing phase., Case Presentation: A 48-year-old female presented with chief complaint of MAL progressive gingival recession (GR). Attachment loss of 3-4 mm and lack of both KT and AG were documented. Primary treatment outcomes objectives were GR cessation, establish KT, increase GT and AG. A secondary outcome was decreasing GR., Conclusion: The mCAF + CTGkt procedure resulted in KT increase, phenotype modification to establish thick GT and adequate AG, and decreased GR. It addressed unique features of MAL anatomy. Postoperative healing outcomes were not negatively impacted by normal oral functioning., (© 2020 American Academy of Periodontology.)

The coronally advanced flap technique is one of the most commonly used approaches for treating gingival recession. Several modifications of the technique have been proposed over the years, making it a highly predictable treatment option for gingival recession; however, as dental implants are structurally and biologically different from natural teeth, a further modification of the conventional coronally advanced flap technique has been suggested to overcome the challenges posed by the treatment of peri-implant soft tissue dehiscences. The present article aims to describe the state of the art of the technique at implant sites presenting with peri-implant soft tissue dehiscences, and highlight the main differences between this and the coronally advanced flap approach in natural teeth. The timing of crown removal and abutment modification/replacement are discussed, along with the different methods for management of the flap and connective tissue graft that are recommended at implant sites. The outcomes of this approach compared to the conventional coronally advanced flap technique, and other approaches are also presented.

The prediction of anatomical structures within the surgical field by artificial intelligence (AI) is expected to support surgeons' experience and cognitive skills. We aimed to develop a deep-learning model to automatically segment loose connective tissue fibers (LCTFs) that define a safe dissection plane. The annotation was performed on video frames capturing a robot-assisted gastrectomy performed by trained surgeons. A deep-learning model based on U-net was developed to output segmentation results. Twenty randomly sampled frames were provided to evaluate model performance by comparing Recall and F1/Dice scores with a ground truth and with a two-item questionnaire on sensitivity and misrecognition that was completed by 20 surgeons. The model produced high Recall scores (mean 0.606, maximum 0.861). Mean F1/Dice scores reached 0.549 (range 0.335-0.691), showing acceptable spatial overlap of the objects. Surgeon evaluators gave a mean sensitivity score of 3.52 (with 88.0% assigning the highest score of 4; range 2.45-3.95). The mean misrecognition score was a low 0.14 (range 0-0.7), indicating very few acknowledged over-detection failures. Thus, AI can be trained to predict fine, difficult-to-discern anatomical structures at a level convincing to expert surgeons. This technology may help reduce adverse events by determining safe dissection planes., (© 2021. The Author(s).)

Introduction: The infringement of supracrestal tissue attachment by subgingival restorative margins, extensive caries, and root fractures, can compromise the periodontal health, resulting in inflammation and loss of periodontal supporting tissues. This report describes a case of a root fracture on the upper left central incisor that was successfully treated using a conservative approach, by applying the restorative alveolar interface (RAI) management combined with tunnel technique and a subepithelial connective tissue graft (SCTG)., Case Presentation: A 24-year-old male patient presented with a provisional single-unit fixed prosthesis on his upper left central incisor, in function for 4 years, with the chief complaint of prosthesis discoloration. After clinical and radiographic examination, a diagnosis of root fracture was established. Following the removal of the provisional prosthesis, a full-thickness flap was elevated creating a tunnel. The elimination of the fracture line/angle, root recontouring, and planning was then performed with the aid of a conical long diamond bur and periodontal curets. Additionally, an SCTG was placed buccally into the tunnel. The final zirconia layered with E-max crown was placed 6 months after surgery. At 12- and 24-month follow-up, the periodontal tissues presented healthy aspect, no bleeding on probing, and a 4-mm probing depth., Conclusions: Surgical repositioning of the restorative margin can be an alternative and conservative treatment approach to compromised teeth with subgingival fracture line/angle. However, case selection should be carefully considered and restorability assessed as limitations might apply., (© 2020 American Academy of Periodontology.)

Introduction: The aim of this case series was to assess the feasibility of a graft modification to increase its length when treating multiple adjacent gingival recessions with only one harvesting site at the palate and respecting the safety zone., Case Series: Nineteen recessions were treated in four consecutive patients with a modified coronally advanced tunnel and a modified connective tissue graft. An 8-mm height connective tissue graft was harvested by the single-incision technique, the graft was split longitudinally, achieving 4-mm height and double the length. Changes in recession depth, keratinized tissue height, mean and complete root coverage, and esthetic score were analyzed at 6 months. The technique allows to harvest a connective tissue graft up to 58-mm length with a single palatal site. Complete root coverage was achieved in 15/19 recessions (78.94%), with a mean root coverage of 82.90%. The mean recession depth was reduced by 1.31 mm and the keratinized tissue increased by 0.69 mm. The esthetic outcome score was 9.26/10., Conclusion: This graft modification technique allows increasing significantly the graft length up to 58 mm without any modification of the surgical harvesting procedure. Therefore, it can be suggested to reduce the morbidity., (© 2021 American Academy of Periodontology.)

Introduction: When gingival recession is combined with cervical abrasion, root coverage outcomes are less predictable due to the challenging adaptation of the connective tissue graft (CTG) to the marked root step. Removing additional tooth structure can improve soft-tissue adaptation with the downside of a possible increase in dental hypersensitivity or pulpitis. Therefore, the aim of this report was to demonstrate a surgical technique using two grafts which does not require any further modification of the root surface, in order to successfully treat recession associated with deep cervical abrasion., Case Presentation: A case of gingival recession associated with a deep root step and cemento-enamel junction alteration (B+; abrasion depth > 1 mm) was successfully treated via a bilaminar grafting technique using two CTG layers covered by a coronally advanced flap (CAF). The tooth surface was polished and did not receive any grinding, blending, planing, or other alterations. Complete recession coverage, complete abrasion coverage, and resolution of baseline sensitivity were achieved 1 year after surgical intervention and were maintained for 19 years with further coronal displacement of the gingival margin due to creeping attachment., Conclusions: The double CTG technique showed optimal clinical results in terms of coverage and resolution of hypersensitivity of a recession associated with a deep cervical abrasion. No additional removal of dental tissue was needed, and the clinical outcomes were stably maintained over a long-term follow-up., (© 2021 American Academy of Periodontology.)

The number of clinical trials evaluating adipose-derived mesenchymal stem cells (AD-MSCs), platelet-rich plasma (PRP), and biomaterials efficacy in regenerative plastic surgery has exponentially increased during the last ten years. AD-MSCs are easily accessible from various fat depots and show intrinsic plasticity in giving rise to cell types involved in wound healing and angiogenesis. AD-MSCs have been used in the treatment of soft tissue defects and chronic wounds, employed in conjunction with a fat grafting technique or with dermal substitute scaffolds and platelet-rich plasma. In this systematic review, an overview of the current knowledge on this topic has been provided, based on existing studies and the authors' experience. A multistep search of the PubMed, MEDLINE, Embase, PreMEDLINE, Ebase, CINAHL, PsycINFO, Clinicaltrials.gov, Scopus database, and Cochrane databases has been performed to identify papers on AD-MSCs, PRP, and biomaterials used in soft tissue defects and chronic wounds. Of the 2136 articles initially identified, 422 articles focusing on regenerative strategies in wound healing were selected and, consequently, only 278 articles apparently related to AD-MSC, PRP, and biomaterials were initially assessed for eligibility. Of these, 85 articles were excluded as pre-clinical, experimental, and in vitro studies. For the above-mentioned reasons, 193 articles were selected; of this amount, 121 letters, expert opinions, commentary, and editorials were removed. The remaining 72 articles, strictly regarding the use of AD-MSCs, PRP, and biomaterials in chronic skin wounds and soft tissue defects, were analyzed. The studies included had to match predetermined criteria according to the patients, intervention, comparator, outcomes, and study design (PICOS) approach. The information analyzed highlights the safety and efficacy of AD-MSCs, PRP, and biomaterials on soft tissue defects and chronic wounds, without major side effects.

Background/purpose: Computer-assisted tissue imaging and analytical techniques were used to clarify the histomorphological structure of hepatic connective tissue as a practical guide for surgeons., Methods: Approximately 5000 histological slides were prepared from liver specimens of five autopsied patients. Three-dimensional (3D) reconstruction was performed and subjected to computer imaging analysis. Scanning electron microscopy was also performed on the liver specimens., Results: The 3D reconstructed images revealed the running form of the vasculature and the relationship between the hepatic lobule and connective tissue. The hepatic capsule or portal pedicle was consistently located at the periphery of the hepatic lobules. An artificial intelligence random forest approach clearly segmented hepatic cells, type I collagen (CF), type III collagen (RF), and other cells. The hepatic lobule, portal region, and hepatic capsule were significantly distinguished based on CF and RF occupancy. The capsule directly covering the liver lobule with an RF concentration up to 87% was provisionally named the proper hepatic capsule. The existence of a proper hepatic ligament with distinct occupation rates of CF and RF was also suggested., Conclusions: The identified proper hepatic capsule and ligament can be important markers for demarcating the dissecting layer during surgical procedures., (© 2020 The Authors. Journal of Hepato-Biliary-Pancreatic Sciences published by John Wiley & Sons Australia, Ltd on behalf of Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: During the posterior approach, it has been shown that a significant reduction in dislocation rate can be achieved with the repair of the posterior soft tissue. However, no consensus exists about the best way to perform this repair. This review aimed to compare the transosseous with transmuscular repair of the posterior soft tissue in total hip arthroplasty (THA)., Methods: We conducted a meta-analysis to identify studies involving transosseous versus transmuscular repair of the posterior soft tissue in THA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang database, up to July 2020. Finally, we identified 1417 patients (1481 hips) assessed in seven studies., Results: Compared with transmuscular repair, transosseous repair resulted in less incidence of dislocation (P = 0.003), less blood loss during operation (P < 0.00001) and lower VAS score within 3 months (P = 0.02). There were no significant differences in terms of trochanteric fracture rate (P = 0.56), Harris hip score at 3 months (P = 0.35) and 6 months (P = 0.89), VAS score within 6 months (P = 0.53), and operation time (P = 0.70) between two groups., Conclusion: The lower dislocation rate, less blood loss, and lower VAS scores after operation supported transosseous repair's superiority to transmuscular repair. Besides, no additional medical cost and operating time were associated with transosseous repair compared with transmuscular repair. Hence, we recommend that transosseous repair be chosen first by orthopedists when performing reconstruction of the posterior soft tissue in THA via a posterolateral approach. Given the relevant possible biases in our meta-analysis, we required more adequately powered and better-designed RCT studies with long-term follow-up to reach a firmer conclusion.

An estimate of about 50% of new liver cancer cases worldwide occur in China every year.Surgical resection is still the major treatment choice for longer survival of patients with hepatocellular carcinoma. Blocking hepatic blood flow and reducing intraoperative bleeding ensure the success of the operation. Anatomic separation of hepatic hilar region is the precondition of hepatic inflow occlusion. The hepatic hilar plate system involves a thick layer of connective tissue covering the hepatic inflow ducts of hepatic hilar region. The descending part of hilar plate assists in reducing the anatomical difficulty of the hepatic hilar region. The "forth porta hepatis" that is hidden in the hepatic hilar plate system involves the accumulation area of "short hepatic portal veins" .The communicating branch vessels between the hepatic inflow vessels form the anatomical basis in reducing the indocyanine green fluorescence stain effect.The relatively fixed position of the hepatic portal plate is considered as a positioning marker for accurate liver resection. The intrahepatic Glisson sheath is connected with thick connective tissue of the hepatic portal panel system, and is regarded as the physical barrier in limiting the proliferation and hypertrophy of hepatocytes and continuation of hepatic portal panel system in the liver.This paper summarizes the anatomy and application of hepatic hilar plate system during hepatobiliary surgery.

Background: The anatomy of soft tissues around dental implants is extremely important to prevent inflammatory periimplant diseases and ensure healthy, stable and long-term survival of a dental implant. Various methods and materials for increasing the physiological thickness of tissues have been described including connective tissue graft (CTG) and xenogenic collagen matrix (XCM). While assessing various materials it is necessary to establish objective measurement method to determine the minimum amount of tissue thickness to maintain a stable level of bone around the implant. The aim of the study was to determine the effect of soft tissues in the implant area on the marginal bone level in the implant area and to define of the critical gingival thickness to minimize marginal bone level (MBL) loss., Methods: 75 bone level implants (Conelog® Camlog, Switzerland) were inserted in the aesthetic area. Thickening of soft tissues was performed using CTG and XCM. 12 months after the loading with final restoration, the thickness of soft tissues in the implant area was examined with ultrasound USG device (Pirop®, Echoson, Poland), and each implant was subjected to RVG examination, where MBL loss was determined., Results: A tendency to occur less MBL loss was found when thicker gingiva was present. The higher soft tissue thickness was, the lower MBL loss has occurred. A critical value for tissue thickness was determined as TKT ≤ 2.88., Conclusions: In case of thin biotype soft tissue augmentation is required when value of tissue thickness in ultrasound measure is less than 2.88 mm., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

We introduce a new model for connective tissue damage in blunt dissection, which is a very important process in neurosurgery simulation. Specifically, the tool-tissue interaction between the instrument and connective tissue is incorporated into the model of connective tissue damage. This damage develops with the evolution criterion due to the effect of the external load. The tetrahedral mesh in the soft tissue model is removed for the representation of rupture as the damage accumulates to the threshold value. Analysis and experiments show that the connective tissue damage model provides stable, visually realistic results for the simulation of the connective tissue rupture process. The stiffness of the connective tissue decreases as the damage accumulates. The proposed model for connective tissue damage was incorporated into the development of a neurosurgery simulator, in which blunt dissection of a brain tumor was simulated., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Prior studies have compared the posterior capsule repair group in primary total hip arthroplasty by posterior approach with the control group without posterior capsule repair suggesting that the posterior capsule repair group had better clinical outcomes. However, it is still a controversy which treatment is more helpful for hip diseases. The purpose of our article is to obtain the postoperative outcomes between the 2 procedures., Methods: We performed a systematic search by browsing the MEDLINE, EMBASE, Cochrane Library. There is no restriction on the date of publication. Before we submit our manuscript, we have re-searched the literatures again, including the articles which directly compared the postoperative outcomes of the 2 procedures., Results: A total of 8 comparative studies were included in our meta-analysis. The posterior capsule repair group showed less dislocation rate, higher HHS, and even less postoperative bleeding volume. Meanwhile, there is no significant difference in ROM between 2 groups., Conclusion: In conclusion, according to current evidences, repairing posterior capsule during primary THA may have better functional outcomes, less dislocation incidence, and less loss of blood.

Background: Recently, a hypertrophic labrum has been reported in the absence of hip dysplasia, which can possibly contribute to an acetabular labral tear., Purpose: To compare the clinical outcomes and complications, including the incidence of iatrogenic acetabular labrum and cartilage injury, in patients with tears of hypertrophic versus morphologically normal acetabular labra over a minimum follow-up period of 2 years and to assess the morphologic changes at follow-up computed tomography arthrography in the 2 groups., Study Design: Cohort study; Level of evidence, 3., Methods: Between January 2010 and December 2016, 20 patients (22 hips) with a hypertrophic labrum underwent arthroscopic hip surgery. A total of 22 patients (22 hips) without a hypertrophic labrum were assigned to the control group based on matching criteria, including age, sex, body mass index, labral tear, and labral repair. Clinical outcomes were assessed with the visual analog scale score, UCLA activity scale score (University of California, Los Angeles), and modified Harris Hip Score. Radiologic outcomes were assessed through serial radiography. Patients were followed for at least 2 years., Results: The mean age at surgery was 42 years. The most common cause of arthroscopic surgery in the study group was an isolated acetabular labral tear without any bony structural abnormalities (68.2%, 15 of 22 hips). All improvements in both groups were statistically significant at the last postoperative follow-up ( P < .001). Although the radiologic and clinical outcomes were not significantly different between the groups, the complication rates, including iatrogenic labral perforations and cartilage injury, were significantly higher in patients with hypertrophic acetabular labral tears (9 vs 3, P = .042). The patient-reported satisfaction scores at the last postoperative follow-up were 8.4 and 7.9 in the study and control groups, respectively ( P = .351)., Conclusion: The high rates of patient-reported satisfaction and the clinical outcomes after arthroscopic repair in both groups are encouraging. Arthroscopic treatment in patients with hypertrophic acetabular labral tears should be carefully performed to prevent iatrogenic injury during the surgery, and isolated hypertrophic labral tears can have good results after repair.

Study Design: Prospective observational study-basic science (Level 1)., Objective: The aim of this study was to compare expression of functional groups of genes within the atrophic, myogenic, fibrogenic, adipogenic, and inflammatory pathways between paraspinal muscle biopsies from individuals with acute and chronic lumbar spine pathology., Summary of Background Data: Low back pain is a complex and multifactorial condition that affects a majority of the general population annually. Changes in muscle tissue composition (i.e., fatty and fibrotic infiltration) are a common feature in individuals with lumbar spine pathology associated with low back pain, which often results in functional loss. Understanding the molecular underpinnings of these degenerative changes in different phases of disease progression may improve disease prevention and treatment specificity., Methods: Intraoperative biopsies of the multifidus muscle were obtained from individuals undergoing surgery for acute (<6-month duration) or chronic (>6-month duration) lumbar spine pathology. Expression of 42 genes related to myogenesis, atrophy, adipogenesis, metabolism, inflammation, and fibrosis were measured in 33 samples (eight acute, 25 chronic) using qPCR, and tissue composition of fat, muscle, and fibrosis was quantified using histology., Results: We found that tissue composition of the biopsies was heterogeneous, resulting in a trend toward lower RNA yields in biopsies with higher proportions of fat (r <-0.39, P < 0.1). There were no significant differences in gene expression patterns for atrophy (P > 0.635), adipogenesis (P > 0.317), myogenesis (P > 0.320), or inflammatory (P > 0.413) genes after adjusting for the proportion of muscle, fat, and connective tissue. However, in the fibrogenesis pathway, we found significant upregulation of CTGF (P = 0.046), and trends for upregulation of COL1A1 (P = 0.061), and downregulation of MMP1 and MMP9 (P = 0.061) in the chronic group., Conclusion: There is increased fibrogenic gene expression in individuals with chronic disease when compared to acute disease, without significant differences in atrophic, myogenic, adipogenic, or inflammatory pathways, suggesting increased efforts should be made to prevent or reverse fibrogenesis to improve patient function in this population., Level of Evidence: N/A.

Endovascular repair of thoracic aortic diseases can provide satisfactory outcomes in elective and certain emergency cases involving the descending thoracic and aortic arch. However, open repair remains the gold standard method of aortic root pathologies and certain aortic arch pathologies, such as extended dissection. Nevertheless, the use of endovascular stenting in patients with connective tissue disorders has not been fully explored because the aortic tissues are fragile and the likelihood of keeping the stent in place is low because of its progressive dilatation and subsequent requirement for open repair at a later stage when the stent graft fails. Our brief review focuses on current evidence of the use of stents in patients with connective tissue disorders and whether such practice can be expanded further.

Sialadenoma papilliferum is a benign salivary tumour which rarely occurs in the bronchial tree. Up to now, only four cases of pulmonary papillary sialadenoma have been reported in the literature. We discuss the case of a male patient with an accidental finding of a middle lobe nodule. The patient underwent a minimally invasive anatomical resection of the lobe to remove the lesion; the postoperative course was regular, and he was healthy at the last follow-up.

Objective: The purposes of this split-mouth pilot study were to investigate the efficacy of the Er:YAG laser use for the de-epithelialization of the palatal graft in the treatment of the multiple gingival recessions using the bilaminar procedure and also to evaluate the patient-reported esthetic outcomes after 6 months. Materials and methods: Five systemically healthy participants with total 28 bilateral-multiple adjacent maxillary Miller I recessions were included. The treatment was performed with the bilaminar technique [coronally advanced flap (CAF)+de-epithelialized free gingival graft]. De-epithelialization procedure was done with scalpel (control site) or Er:YAG laser (Versawave, Hoya ConBio, San Francisco, CA; 40 hz, 50 mJ/pulse), under water irrigation, noncontact mode (∼1 mm away from the target tissue) in sweeping motion with chisel-type laser (test site). Root coverage and patient-reported outcomes were evaluated at 6 months after the operations. Results: Clinical outcomes of the both treatment sites did not show any statistically significant differences except for the gingival thickness parameter. However, patient-reported outcomes regarding the esthetic appearance of the gingiva was detected in favor of the Er:YAG laser applied sites. Conclusions: Within the limits of the study, it can be concluded that both de-epithelialization techniques were highly effective at 6 months. However, Er:YAG laser-applied grafted sites revealed more uniform and esthetic gingival appearance compared with scalpel-used grafted sites.

Introduction . Soft tissue defects in the distal leg and foot are challenging conditions for reconstruction. The widely used reverse sural fascio-cutaneous flap (RSFCF) has been reported with large variation in complication frequency. Some authors reported higher complications in the diabetic population when compared with trauma patients. We compared the reliability of the RSFCF in treating such defects among both populations. Methods . This is a retrospective series with a prospective data collection of 24 patients (11 with type 2 diabetes and 13 in trauma settings) treated with an ipsilateral RSFCF for soft tissue defects of the distal leg and the rear foot. Healing events and complications were recorded and compared for both groups. The mean follow-up was 32 months. Results . Diabetic group versus trauma group showed the following results; mean flap healing time of 24 versus 22 days, donor site healing time of 14 versus 16 days, 1 total flap necrosis in both groups, 3 versus 2 cases of skin edge necrosis, 2 cases of temporary venous congestion in both groups, and 8 versus 10 cases of transient hypoesthesia of the lateral border of the foot. No infection was encountered in both groups and no recurrence of infection in the primary infected diabetic patients. Conclusions . We found the RSFCF to be useful, reproducible, and reliable in treating soft tissue defects with a very low frequency of serious complications. Diabetic patients were found to have similar outcomes when compared with trauma patients. Therefore, diabetes might not be a major factor of flap failure. Levels of Evidence: Level III: Therapeutic.

Bacterial nanocellulose (BNC) is a promising biomedical material. However, the haemocompatibility (haemolysis and thrombogenicity) and acute and sub-chronic immune responses to three-dimensional (3D) BNC biomaterials have not been evaluated. Accordingly, this manuscript focused on the effect of 3D microporosity on BNC haemocompatibility and a comparison with 2D BNC architecture, followed by the evaluation of the immune response to 3D BNC. Blood ex vivo studies indicated that compared with other 2D and 3D BNC architectures, never-dried 2D BNC presented antihemolytic and antithrombogenic effects. Nevertheless, in vivo studies indicated that 3D BNC did not interfere with wound haemostasis and elicited a mild acute inflammatory response, not a foreign body or chronic inflammatory response. Moreover, compared with the polyethylene controls, the implant design with micropores ca. 60 µm in diameter showed a high level of collagen, neovascularization and low fibrosis. Cell/tissue infiltration increased to 91% after 12 weeks and was characterized by fibroblastic, capillary and extracellular matrix infiltration. Accordingly, 3D BNC biomaterials can be considered a potential implantable biomaterial for soft tissue augmentation or replacement.

Image-guided ablation is performed by percutaneously introducing ablation probes to deliver energy into a tumor to destroy it in a controlled and localized fashion. Ablation modalities can be broadly classified as thermal or non-thermal based on the mechanism of tumor destruction and are performed using different types of image guidance for planning, delivering and follow-up of the treatment. Ablation is performed in a minimally invasive fashion, providing greater residual organ preservation with minimal morbidity to the patient. Image-guided ablation is being used in the clinic for the treatment of primary and metastatic tumors, and this article reviews state of the art for the treatment of malignancies in the liver, lung, kidney and musculoskeletal tissue., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Subepithelial connective tissue graft (SCTG) is an essential therapeutic tool in periodontal plastic surgery and implantology. The aim of this preliminary study was to observe and make a histological and histomorphometric comparison of the composition of subepithelial connective tissue grafts (SCTGs) harvested from the palatal mucosa by two different harvesting techniques: mucoperiosteal (lamina propria and complete submucosa including periosteum) and mucosal (lamina propria and a portion of the submucosa). The main hypothesis proposes that SCTG harvested with the mucosal technique contains a greater proportion of connective tissue proper (CTP) and a lower proportion of adipose tissue (AT) than the mucoperiosteal technique. Twenty healthy patients who required SCTG for different purposes were selected and assigned to one of the two following groups: group A (n=10; mucoperiosteal harvesting technique) and group B (n=10, mucosal harvesting technique). The histological sample was obtained by removing a 2 mm thick slice from the most distal portion of the graft. The proportions of adipose tissue (AT), connective tissue proper (CTP) and vascular tissue (VT) were evaluated. In group A, histomorphometric analysis showed that CTP accounted for 58.2% of the graft while AT accounted for 32.64%. In group B, the proportions of CTP and AT were 79.86% and 11.93%, respectively. The differences between groups were statistically significant for both tissues (p< .05). In contrast, no statistically significant difference was observed in the proportion of VT. Within the limitations of this study, the results show that the SCTGs harvested by the mucosal technique contain a greater proportion of CTP and a lower proportion of AT than those obtained by the mucoperiosteal technique, whereas the proportion of VT does not differ. Further long-term clinical and histological studies with more samples are needed to evaluate the clinical implications of SCTG composition., (Sociedad Argentina de Investigación Odontológica.)

Distal metatarsal (MT) osteotomies have been used in mild or moderate cases of hallux valgus (HV) and proximal MT osteotomy has been considered the treatment of choice for severe deformities. A distal osteotomy could achieve a greater degree of correction by the addition of a distal soft-tissue procedure and be used to treat also severe deformity. Limited evidence about the use of the percutaneous subcapital osteotomy (SCOT); a type of MT osteotomy, in combination of a soft tissue procedure, is available. We evaluated this procedure routinely used in our clinic. A total of 30 consecutive patients treated in our hospital from September 2012 to April 2015 with SCOT combined with lateral soft tissue release were included in this retrospective review. Outcomes assessed included radiological parameters: HV angle (HVA) and intermetatarsal angle (IMA), clinical evaluation using the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complication rate. In 12 of the 30 patients included, the pathology was bilateral, comprising a total of 42 cases. The overall correction of the angles was statistically significant (P < .001), changing from a HVA of 28.2° and IMA of 13.5° preoperatively to 8.0° and 6.0° postoperatively, respectively. The cases were divided into mild-moderate (34/42) and severe (8/42). Both groups showed a statistically significant correction in the angles, 3 months after surgery (P < .001). The AOFAS score showed a median of 49 points (n = 24) preoperatively and of 95 points (n = 40) at the end of follow-up. The complication rate at end of follow-up was 19% (8/42). After a minimum follow-up of 1 year, our technique for HV correction results in a clinically relevant improvement of the radiological parameters and AOFAS score in mild to severe deformities. Combination with lateral release could be a meaningful surgical alternative for the treatment of severe cases to help decrease the risk of recurrence. Levels of Evidence: Level IV.

The objectives of this study were to clinically and histologically assess the capacity of bilaminar subepithelial connective tissue grafts (SCTGs) alone or in combination with gingivoplasty (Gv) to increase the keratinized gingiva width (KGW) in contralateral mandibular sites lacking KG (10 patients, 42 sites). The effects of Gv timing (1 vs 2 months) and technique (blade vs laser) were also evaluated. SCTGs alone resulted in mean KGW increase of 0.1 to 0.7 mm. Laser-Gv significantly increased KGW by an additional 1.9 mm at 4 months postabrasion as opposed to 0.9 mm achieved with blade-Gv. Histologically, laser-treated sites displayed parakeratinization with more pronounced rete pegs than observed in blade-abraded sites.

Postoperative complications may occur during the healing of palatal donor sites due to disturbed blood circulation of palatal tissues. Therefore in this study, blood flow was measured by Laser Speckle Contrast Imaging (LSCI) in seven patients after connective-tissue harvesting. The slope in blood-flow elevation within the first 3 days as well as time needed for maximum reperfusion were calculated. Each surgical site was assessed by clinical examination on day 3. In donor sites with secondary-intention wound healing, postoperative blood flow was elevated with significant delay compared to the surrounding tissues and to the primarily healed wound. Reperfusion time and healing score were strongly correlated (r = 0.87, P < .001), as were the slope and clinical rank (r = -0.85, P < .001). LSCI proved to be an objective method to assess individual wound-healing time and to predict the quality of wound healing.

Objectives: To present a modified technique in artificial urinary sphincter (AUS) placement that is associated with low rates of erosion and infection in a high-risk population., Patients and Methods: After Institutional Review Board approval, we identified patients who underwent primary AUS placement using the modified technique between January 2007 and November 2015. Our modification consists of preserving the dorsolateral fibromuscular tissue surrounding the bulbar urethra and horizontally transecting the ventral bulbospongiosus muscle during urethral cuff placement. Preoperative variables such as radiotherapy (RT) and bladder neck contractures were recorded. Effectiveness and complications including infections, erosions, and re-operations were recorded at follow-up., Results: The new technique was used on 208 patients: 40% had a history of RT, including 15% who had had a salvage radical prostatectomy; 26% had had previous bladder neck contractures. No patients developed infection. Overall, erosion occurred in six (2.9%) patients and spontaneous erosions occurred in two (0.9%) during the study period. In all, 21 patients underwent re-operation for device failure. The probability of re-operation for 'any' reason was 7% (95% confidence interval [CI] 4-12%) at 1 year. The 1-year social continence rate was 74% (95% CI 67-81%)., Conclusion: Preservation of dorsolateral fibromuscular tissue during AUS placement is an effective means to achieve a low risk of erosions. Our modified technique is safe with low infection and erosion rates, whilst maintaining good functional outcomes despite a high-risk population., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

Aim: To analyze experimentally the outcomes of xenotransplantation (cadaveric artery, decellularized cadaveric artery) for tunica albuginea defects repair., Material and Methods: The study included 60 chinchilla rabbits. Rabbits underwent local replacement of tunica albuginea. Animals were divided into 2 groups (group 1 - human cadaveric artery, group 2 - decellularized cadaveric artery). The result was considered after 7, 14 and 30 days postoperatively., Results: Tendency to stasis, sludge-phenomenon and ultimately development of fibrosis of transplantation area were histologically observed in group 1 after 30 days. In group 2 luminal surface of decellularized artery was smoothed, fibrin and blood elements were absent. In group 1 mean level of C-reactive protein was 3.86±0.43, 1.17±0.2 and 0.73±0.16 mg/L after 7, 14 and 30 days respectively. In group 2 the same values were 0.33±0.03, 0.23±0.03 and 0.11±0.02 mg/L. Differences were significant (t =-46.28, t = -25.95, t = -14.84; p<0.0001).

Background: The mesenteric approach is an artery-first approach to pancreaticoduodenectomy for pancreatic cancer, which starts with the dissection of connective tissues around the superior mesenteric artery. The procedure aims for early confirmation of resectability by checking the surgical margin around the superior mesenteric artery first during the operation. It also aims to decrease intraoperative blood loss by early ligation of the inferior pancreaticoduodenal artery and to increase R0 rate by complete clearance of the lymph nodes around the superior mesenteric artery and pancreatic head plexus II, the most favorable positive margin site for pancreatic ductal adenocarcinoma. Furthermore, it aims to avoid the spread of cancer cells during operation (nontouch isolation technique). The MAPLE-PD (Mesenteric Approach vs. Conventional Approach for Pancreatic Cancer during Pancreaticoduodenectomy) trial investigates whether the mesenteric approach can prolong the survival of patients with pancreatic ductal adenocarcinoma who undergo pancreaticoduodenectomy compared with the conventional approach., Methods/design: The MAPLE-PD trial is a Japanese multicenter randomized controlled trial that compares the surgical outcomes between the mesenteric and conventional approaches to pancreaticoduodenectomy. Patients with pancreatic ductal adenocarcinoma scheduled to undergo pancreaticoduodenectomy are randomized before operation to either a conventional approach (arm A) or a mesenteric approach (arm B). In arm A, the operation starts with Kocher's maneuver. At the final step of the removal procedure, the connective tissues around the superior mesenteric artery are dissected. In arm B, the operation starts with dissection of the connective tissues around the superior mesenteric artery and ends with Kocher's maneuver. In total, 354 patients from 15 Japanese high-volume centers will be randomized. The primary endpoint is overall survival by intention-to-treat analysis. Secondary endpoints include intraoperative blood loss, R0 rate, and recurrence-free survival., Discussion: If the MAPLE-PD trial shows the oncological benefits of the mesenteric approach for patients with pancreatic ductal adenocarcinoma, this procedure may become a standard approach to pancreaticoduodenectomy., Trial Registration: ClinicalTrials.gov, NCT03317886 . Registered on 23 October 2017. University Hospital Medical Information Network Clinical Trials Registry, UMIN000029615 . Registered on 15 January 2018.

Many papillary preservation flap techniques exist for both resective and regenerative purposes. This article describes a papillary retention design based on palatal access showing a successful long-term outcome. The papilla preservation approach detailed here, which is a modification of Friedman's beveled flap for the palate, circumvents any manipulation of interproximal or buccal tissue, leaving papillary tissue untouched. Indications for this approach are very specific and its application is somewhat limited. However, the aim of the papillary retention flap as discussed is to eradicate pocket depths exceeding 5 mm and possibly regenerate hard and connective tissue in these exclusive locations. This strategy may permit access to the labial portion of the interproximal root in particular cases.

Background: Minimally invasive techniques for hallux valgus have been widely used to treat mild to moderate hallux valgus deformities. The purpose of this study was to evaluate the clinical and radiographic outcomes of distal linear metatarsal osteotomy (DLMO), which is one of the minimally invasive techniques, for severe hallux valgus., Methods: 95 patients (141 feet) with severe hallux valgus underwent DLMOs. Lateral soft tissue release (LSTR) was performed at the same time for the cases selected by an original manual test. The satisfaction level, the Japanese Society of Surgery of the Foot (JSSF) hallux scale score, and weight-bearing radiographs of the foot were assessed preoperatively and after more than 24 months. In addition, the clinical and radiographic outcomes were compared among three groups divided by the kind of LSTR: no LSTR; manual correction; and open release through skin incision., Results: Although the first metatarsal bone was significantly shortened, dorsiflexed, and elevated on postoperative radiographs, the rate of satisfaction was 87.2% (123/141), and the mean JSSF hallux scale score improved significantly from 60.4 (44-73) to 90.4 (65-100). The mean hallux valgus and intermetatarsal angles also improved significantly from 45.5° (40.0-60.0°) to 10.3° (-28.0-40.9°) and from 19.9° (14.0-28.7°) to 8.3° (-1.6-18.5°), respectively. Delayed union (18 feet), metatarsalgia (16 feet), recurrence (22 feet), and hallux varus (22 feet) were observed, and they were more obvious in DLMO combined with open release through a skin incision., Conclusions: DLMO combined selectively with LSTR is an effective procedure for correcting severe hallux valgus. However, the indication for open release with DLMO should be considered carefully., (Copyright © 2018. Published by Elsevier B.V.)

The nasal alae and the soft-tissue triangles are delicate structures, the contours of which are largely dependent on soft tissue and the indirect influence of the lower lateral cartilages. Creating appropriate and continuous contour from the tip lobule to the alar lobule can be challenging. The alar contour graft is one reliable method of achieving predictable contour. However, alar contour grafts of ideal length may be scarce. The butterfly graft is a simple, reliable, and predictable method of providing support in the region of the soft triangle, and spans the region between the tip lobule and alar lobule, thereby balancing the transition between these regions.