Treatment Algorithm for Surgical Correction of Lower Eyelid Bags and Tear Trough Deformity Based on Barton Grading System.

Facial rejuvenation procedures for lower eyelid bags and tear trough deformity have recently gained increasing attention. This study introduced a treatment algorithm tailored to the severity of tear trough deformity, categorized using the Barton grading system, to tackle this concern effectively. One hundred seventy-six patients with combined lower eyelid bags and tear trough deformity underwent lower lid blepharoplasty at our center between 2018 and 2023. Preoperative assessment utilized the Barton grading system to categorize the severity of tear trough deformity, guiding personalized surgical approaches for each patient. Postoperative outcomes, including satisfaction levels, complications, and tear trough deformity improvement, were evaluated. Following surgery, 175 out of 176 patients achieved a reduction to Barton grade level of 0. Postoperative satisfaction scores averaged 4.4, with a satisfaction rate of 96.6%. Complications were minimal, including mild postoperative ectropion in patients and single occurrences of postoperative hematoma, infection, insufficient improvement, and recurrence. Our treatment algorithm offers a straightforward and effective approach for addressing tear trough deformity and lower eyelid bags. Further research is warranted to validate these findings.

Pre-expanded Brachial Artery Perforator Propeller Flap: An Addition to the Armamentarium for Postburn Axillary Contracture Reconstruction.

BACKGROUND: Postburn axillary contracture is a common complication that leads to functional impairment and unsatisfactory aesthetic outcomes. This article aims to present our experience with axillary contracture reconstruction using pre-expanded brachial artery perforator propeller (BAPP) flaps and provide a systematic review of other regional or free flaps. METHODS: This retrospective study included patients who underwent postburn axillary contracture reconstruction using pre-expanded BAPP flaps from 2015 to 2022. Data on the flap characteristics and function of the affected shoulders were recorded. A systematic review was conducted by retrieving studies that assessed the outcomes of regional or free cutaneous/fasciocutaneous flaps for treating axillary contracture from PubMed, Web of Science, EMBASE, and Scopus published before October 1, 2023. RESULTS: Twelve pre-expanded BAPP flaps measuring up to 26 cm × 11 cm (mean, 116.9 cm 2) survived completely with no major complications, and the donor sites were closed primarily. The average range of shoulder abduction increased from 77.9° to 141.7° (p=0.002). The systematic review included 34 articles, reporting 12 regional and three free flaps. The most reported flaps were the thoracodorsal artery perforator flap, scapular flap, and parascapular flap. The overall complication rate ranged from 0 to 25%, and the average change in shoulder abduction ranged from 72.5° to 99.4°. CONCLUSIONS: Pre-expanded BAPP flaps can be effectively used for reconstructing postburn anterior axillary fold contracture. The donor site availability and the specific axillary contracture type should be considered when selecting a regional or free flap.

Finding Perforator "Freeway" for Design Optimization of Expanded Flaps by Indocyanine Green Angiography.

SUMMARY: Indocyanine green angiography (ICGA) is a useful tool for the visual assessment of superficial blood flow. Herein, we used ICGA to visualize perforator branches and linking vessels to provide a road map for flap design of an expanded flap. Twenty-eight expansions were planned to use back-cut technique in 26 patients. ICGA was used to visualize perforator branching pattern with the linking vessels and the venous network in the expanded flap before expander explantation. The appropriate perforator was selected, and the flap was designed following the axiality of its branch linked by true anastomoses. The vein running closely was chosen as the axial vein. The back cut was designed to avoid transection of the axial artery and vein. Patient demographics, defect characteristics, and reconstructive outcomes were assessed. ICGA clearly visualized the perforator branches and the linking vessels in the expanded flap at the head and neck, trunk, and extremity. The back-cut flap containing the axial artery and vein was raised successfully in 27 expansions. The arterial perforator and superficial vein separated greatly and resulted in design modification from back-cut to advancement flap in one expansion. All expanded flaps met the reconstructive needs and exhibited complete survival. ICGA allowed the visualization of the preoperative topography of the vascular network in the expanded flap and helped surgeons locate the vascular axis and perform an appropriate back-cut design for efficient and safe flap transfer.

A New Option to Preserve Esthetics in Perioral Defect Reconstruction With Normal Anatomical Structures: Bipedicled Preexpanded Forehead Flap With Random Skin Flap Extension.

Plastic surgeons charged with reconstructing extensive perioral defects face dual challenges of functional restoration and esthetic considerations. While forehead flaps are commonly used to reconstruct perioral defects, in cases involving partial upper lip defects where normal anatomical structures are preserved, traditional forehead flaps may compromise esthetics. This study aimed to address this issue by employing bipedicled preexpanded forehead flaps based on the frontal branches of the superficial temporal artery (hereafter, "STA-bfb-based preexpanded forehead flap") with random flap extensions to repair perioral defects. Between April 2004 and July 2020, 7 patients (5 males and 2 females; 6 had post-burn facial scars involving the entire lower lip and part of the upper lip, and 1 presented with noma sequelae) underwent perioral defect reconstruction using this approach. Tissue expanders were placed in the forehead donor area, and an STA-bfb-based preexpanded forehead flap with random flap extensions was used to repair the perioral defect. The flap pedicle was divided into 3 weeks. All flaps remained viable with no perfusion-related complications. At follow-up 12 to 96 months later, the color and texture of the flaps demonstrated excellent compatibility with the surrounding skin, suggesting that the use of an STA-bfb-based preexpanded forehead flap with random skin flap extensions is a reliable method for repairing perioral defects. The authors' results have implications for plastic surgeons seeking a solution for challenging perioral defect reconstructions, balancing the need for esthetic outcomes with functional restoration.

Steering Selectivity in Electrocatalytic Furfural Reduction via Electrode-Electrolyte Interface Modification.

Electrocatalytic reduction of biomass-derived furfural (FF) represents a sustainable route to produce furfuryl alcohol (FA) and 2-methylfuran (MF) as a value-added chemical and a biofuel, respectively. However, achieving high selectivity for MF as well as tuning the selectivity between FA and MF within one reaction system remain challenging. Herein, we have reported an electrode-electrolyte interface modification strategy, enabling FA and MF selectivity steering under the same reaction conditions. Specifically, by modifying copper (Cu) electrocatalysts with butyl trimethylammonium bromide (BTAB), we achieved a dramatic shift in selectivity from producing FA (selectivity: 83.8%; Faradaic efficiency, FE: 68.9%) to MF (selectivity: 80.1%; FE: 74.8%). We demonstrated that BTAB adsorption over Cu modulates the electrical double layer (EDL) structure, which repels interfacial water and weakens the hydrogen-bond (H-bond) network for proton transfer, thus impeding FF-to-FA conversion by suppression of the hydrogen atom transfer (HAT) process. On the contrary, FF-to-MF conversion was less affected. This work shows the potential of engineering of the electrode-electrolyte interface for selectivity control in electrocatalysis.

Targeting the tumor microenvironment in primary central nervous system lymphoma: Implications for prognosis.

Primary central nervous system lymphoma (PCNSL) is a rare extranodal non-Hodgkin lymphoma, and there is limited research on its tumor microenvironment (TME). Nevertheless, more and more studies have evidence that TME has essential effects on tumor cell proliferation, immune escape, and drug resistance. Thus, it is critical to elucidate the role of TME in PCNSL. The understanding of the PCNSL TME is gradually unfolding, including factors that distinguish it from systemic diffuse large B-cell lymphoma (DLBCL). The TME in PCNSL exhibits both transcriptional and spatial intratumor heterogeneity. Cellular interactions between tumor cells and stroma cells reveal immune evasion signaling. The comparative analysis between PCNSL and DLBCL suggests that PCNSL is more likely to be an immunologically deficient tumor. In PCNSL, T cell exhaustion and downregulation of macrophage immune function are accompanied by suppressive microenvironmental factors such as M2 polarized macrophages, endothelin B receptor, HLA depletion, PD-L1, and TIM-3. MMP-9, Integrin-ß1, and ICAM-1/LFA-1 play crucial roles in transendothelial migration towards the CNS, while CXCL13/CXCR5, CD44, MAG, and IL-8 are essential for brain parenchymal invasion. Further, macrophages, YKL-40, CD31, CD105, PD-1/PD-L1 axis, osteopontin, galectin-3, aggregative perivascular tumor cells, and HLA deletion may contribute to poor outcomes in patients with PCNSL. This article reviews the effect of various components of TME on the progression and prognosis of PCNSL patients to identify novel therapeutic targets.

A real­world pharmacovigilance study of FDA adverse event reporting system events for daratumumab.

BACKGROUND: Daratumumab, a first-in-class humanized IgG1κ monoclonal antibody that targets the CD38 epitope, has been approved for treatment of multiple myeloma by FDA. The current study was to evaluate daratumumab-related adverse events (AEs) through data mining of the US Food and Drug Administration Adverse Event Reporting System (FAERS). RESEARCH DESIGN AND METHODS: Disproportionality analyses, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN) and the multi-item gamma Poisson shrinker (MGPS) algorithms were employed to quantify the signals of daratumumab-associated AEs. RESULTS: Out of 10,378,816 reports collected from the FAERS database, 8727 reports of daratumumab-associated AEs were identified. A total of 183 significant disproportionality preferred terms (PTs) were retained. Unexpected significant AEs such as meningitis aseptic, leukoencephalopathy, tumor lysis syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, sudden hearing loss, ileus and diverticular perforation were also detected. The median onset time of daratumumab-related AEs was 11 days (interquartile range [IQR] 0-76 days), and most of the cases occurred within 30 days. CONCLUSION: Our study found potential new and unexpected AEs signals for daratumumab, suggesting prospective clinical studies are needed to confirm these results and illustrate their relationship.

2-Pyran-4-Ylidene Malononitrile Based Conjugated Microporous Polymers as Metal-Free Heterogeneous Photocatalysts for Organic Synthesis.

Photoactive conjugated microporous polymers (CMPs) as heterogeneous photocatalysts provide a sustainable alternative to classical metal-based semiconductor photosensitizers. However, previously reported CMPs are typically synthesized through metal catalyzed coupling reactions, which bears product separation, but also increases the price of materials. Herein, a new type of sp2 carbon linked DCM-CMPs are successfully designed and synthesized by organic base catalyzed Knoevenagel reaction using 2,6-Dimethyl-4H-pyran-4-ylidene-malononitrile and aromatic polyaldehydes as monomers. The new polymers feature inherent porosity, excellent stability, and fully π-conjugated skeleton with broad visible-light absorption. They effectively induce the synthesis of benzimidazole compounds under light irradiation, and exhibit wide substrate adaptability with outstanding recyclability.

Utility of contrast-enhanced MRI radiomics features combined with clinical indicators for predicting induction chemotherapy response in primary central nervous system lymphoma.

PURPOSE: To assess the utility of combining contrast-enhanced magnetic resonance imaging (CE-MRI) radiomics features with clinical variables in predicting the response to induction chemotherapy (IC) for primary central nervous system lymphoma (PCNSL). METHODS: A total of 131 patients with PCNSL (101 in the training set and 30 in the testing set) who had undergone contrast-enhanced MRI scans were retrospectively analyzed. Pyradiomics was utilized to extract radiomics features, and the clinical variables of the patients were gathered. Radiomics prediction models were developed using different combinations of feature selection methods and machine learning models, and the best combination was ultimately chosen. We screened clinical variables associated with treatment outcomes and developed clinical prediction models. The predictive performance of radiomics model, clinical model, and combined model, which integrates the best radiomics model and clinical characteristics, was independently assessed and compared using Receiver Operating Characteristic (ROC) curves. RESULTS: In total, we extracted 1598 features. The best radiomics model we selected as the best utilized T-test and Recursive Feature Elimination (RFE) for feature selection and logistic regression for model building. Serum Interleukin 2 Receptor (IL-2R) and Eastern Cooperative Oncology Group (ECOG) Score were utilized to develop a clinical predictive model for assessing the response to induction chemotherapy. The results of the testing set revealed that the combined prediction model (radiomics and IL-2R) achieved the highest area under the ROC curve at 0.868 (0.683, 0.967), followed by the radiomics model at 0.857 (0.681, 0.957), and the clinical prediction model (IL-2R and ECOG) at 0.618 (0.413, 0.797). The combined model was significantly more accurate than the clinical model, with an AUC of 0.868 compared to 0.618 (P < 0.05). While the radiomics model had slightly better predictive power than the clinical model, this difference was not statistically significant (AUC, 0.857 vs. 0.618, P > 0.05). CONCLUSIONS: Our prediction model, which combines radiomics signatures from CE-MRI with serum IL-2R, can effectively stratify patients with PCNSL before high-dose methotrexate (HD-MTX) -based chemotherapy.

Extensive Defect Reconstruction Using Multiple Perforator Propeller Flaps in a Jigsaw Puzzle Approach.

BACKGROUND: Reconstruction of extensive defects remains challenging for plastic surgeons. We report our experience with extensive defect reconstruction using multiple perforator propeller flaps and provide a systematic review of the literature on this approach. METHODS: This retrospective study included patients who underwent defect reconstruction with multiple perforator propeller flaps from 2014 to 2021. A systematic review was conducted by retrieving studies on reconstructive strategy from PubMed, Web of Science, EMBASE, and Scopus published before December 1, 2022. RESULTS: Thirty patients underwent defect reconstruction using 65 perforator propeller flaps. The posterior trunk (66.7%) was the most common site of defects. Complete flap survival was achieved in 61 flaps (93.8%). Partial necrosis of four flaps in three patients and venous congestion of one flap resulted in an overall complication rate of 13.3%. One flap experienced distal tip necrosis in 21 patients undergoing posterior trunk or perineal defect reconstruction, leading to an overall complication rate of 4.7%. Other complications were observed during the reconstruction of defects in the lower extremities (one of five patients) and anterior trunk (two of four patients). In the systematic review, 11 articles involving 74 patients were identified. The commonly reported locations of the defects were the perineum (55.4%) and posterior trunk (33.8%). Flap-related complications included venous congestion, and no flaps were lost. CONCLUSIONS: This study on the use of multiple perforator propeller flaps in a jigsaw puzzle approach demonstrated that the method can be effectively used for extensive posterior trunk and perineal defect reconstruction.

Distally Based Anterolateral Thigh Flap Algorithm for Unexpected Situations during Soft-Tissue Defect Reconstruction around the Knee.

BACKGROUND: The distally based (d) anterolateral thigh (ALT) flap is an effective option for soft-tissue reconstruction around the knee; however, unexpected situations may occur intraoperatively, impeding flap harvest. The authors proposed an algorithm for surgical conversion for unexpected situations encountered intraoperatively. METHODS: Between 2010 and 2021, 61 dALT flap harvests were attempted for soft-tissue defect reconstruction around the knee; 25 patients underwent surgical conversion for anomalies, including lack of a suitable perforator, hypoplasia of the descending branch, and compromised reverse flow from the descending branch. After excluding improper cases, 35 flaps were harvested as planned (group A) and 21 surgical conversion cases (group B) were finally enrolled for analysis. An algorithm was developed based on the cases in group B. Outcomes, including complication and flap loss rates, were compared between groups to verify the algorithm's rationality. RESULTS: In group B, the dALT flap was converted to a distally based anteromedial thigh flap ( n = 8), bipedicled dALT flap ( n = 4), distally based rectus femoris muscle flap ( n = 3), free ALT flap ( n = 2), or other locoregional flap that required additional incision ( n = 4). No differences in outcomes were observed between the two groups. CONCLUSION: The proposed contingency planning algorithm for dALT flap surgery proved rational, as surgical conversion could be made by means of the same incision in most cases, and outcomes generated by the algorithm were acceptable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Soap Film Transfer Printing for Ultrathin Electronics.

Flexible and stretchable electronics have attractive applications inaccessible to conventional rigid electronics. However, the mainstream transfer printing techniques have challenges for electronic films in terms of thickness and size and limitations for target substrates in terms of curvature, depth, and interfacial adhesion. Here a facile, damage-free, and contamination-free soap film transfer printing technique is reported that enables the wrinkle-free transfer of ultrathin electronic films, precise alignment in a transparent manner, and conformal and adhesion-independent printing onto various substrates, including those too topographically and adhesively challenging by existing methods. In principle, not only the pattern, resolution, and thickness of transferred films, but also the curvature, depth, and adhesion of target substrates are unlimited, while the size of transferred films can be as high as meter-scale. To demonstrate the capabilities of soap film transfer printing, pre-fabricated ultrathin electronics with multiple patterns, single micron resolution, sub-micron thickness, and centimeter size are conformably integrated onto the ultrathin web, ultra-soft cotton, DVD-R disk with the minimum radius of curvature of 131 nm, interior cavity of Klein bottle and dandelion with ultralow adhesion. The printed ultrathin sensors show superior conformabilities and robust adhesion, leading to engineering opportunities including electrocardiogram (ECG) signal acquisition and temperature measurement in aqueous environments.

[Principle and clinical application of keloid core excision technique].

Objective: To review the research progress of the principle and clinical application of keloid core excision technique. Methods: The literature on keloid core excision technique at home and abroad in recent years was extensively reviewed, and the principle, development history, indications, advantages and disadvantages of this technique were summarized, and the existing controversies were analyzed. Results: Keloid core excision is a technique to remove the inner fibrous core from the keloid and cover the defect with the keloidal flap. It reduces the wound tension, yields good aesthetic results in the treatment of ear keloids, and reduces the recurrence rate of keloids combining with adjuvant therapies. Conclusion: The keloid core excision technique has specific advantages, yet its overall efficacy remains controversial. Further studies are imperative to explore the mechanisms regarding keloid recurrence and the vascular supply principles of the keloidal flap. It is also necessary to define appropriate surgical indications and safety protocols of this technique.

Utilization of two methods assisting perforator identification for brachial artery perforator propeller flap application.

The brachial artery perforator propeller (BAPP) flap has the advantages of both local and perforator propeller flaps, and it remains relatively underused partly because of the anatomical variations of perforators in the medial arm. We aimed to review our preliminary experience using two different methods for perforator localization of a BAPP flap, including the application of a refined coordinate system (the ABC system) in the medial arm and indocyanine green angiography (ICGA). We evaluated the advantages and disadvantages of these methods and selected the optimal examination mode depending on detailed clinical settings. The perforator was identified for each patient using the ABC system and/or ICGA, depending on the clinical setting. Twenty-two patients underwent soft-tissue reconstructions with 22 BAPP flaps, and perforator localization for all the flaps was performed before surgery using the ABC system. Thirty-one perforators were localized before surgery and marked accordingly, all of which were visualized during surgery, except two, which were not found during the surgery. ICGA was used in six pre-expanded flaps at both stages of surgeries. Twenty-seven perforators were detected before surgery, and all of them were identified during surgery; the previously localized perforators found using the ABC system in the six patients were all reidentified using ICGA. Both the ABC system and ICGA were found to be useful for preoperative perforator localization in BAPP flap transfers. Each method has its unique downsides; however, they can supplement each other to facilitate safe and effective flap elevation. Therefore, selection of the optimal method based on the clinical settings is recommended.

Improving the outcome of distally based anterolateral thigh flap reconstruction: New classification and surgical guidelines.

BACKGROUND: The distally based anterolateral thigh (dALT) flap is associated with a high incidence of venous congestion. This study aimed to investigate factors associated with vascular compromise to improve the outcomes. METHODS: We retrospectively analyzed 41 dALT flap reconstructions performed between November 2010 and February 2023. The dALT flap was classified into type I, II, or III based on the origin (the descending, oblique, or transverse branch) of the chosen perforator. The distance from the pivot point to the superolateral patella, pedicle length, flap reach, complications, and loss rates were analyzed to identify different dALT flap characteristics. RESULTS: The type Ⅰ flap had a shorter pedicle length (type Ⅰ vs. type Ⅱ, p = 0.000; type Ⅰ vs. type Ⅲ, p = 0.000) that primarily reached closer regions (distal third of the thigh anterior/lateral knee). Pedicle lengths were similar between type Ⅱ and Ⅲ flaps (p = 1.000), most of which reached more distal regions (medial/posterior knee or proximal third of the leg). However, the type Ⅲ flaps had a higher complication rate and flap loss rate, although no significant differences were observed (complication rate, p = 0.094; flap loss rate, p = 0.071). CONCLUSIONS: To achieve more desirable outcomes using the dALT flap, preoperative assessment of flap pedicle length and proper intraoperative maneuvers that avoid compromising the reverse blood circulation are necessary.

Virtual reality used in undergraduate orthodontic education.

INTRODUCTION: Undergraduate dental students frequently have reduced clinical experience which presents a challenge for their dental education. Previously, we developed a virtual reality (VR) simulating the whole clinical treatment process of a patient with angle Class II division 1 malocclusion, and the VR also helped to explain some important orthodontic concepts. As a novel teaching tool, this study aims to compare the effects of VR versus traditional case analysis by Power Point (PPT) in inspiring student learning motivation and evaluating learning experience. MATERIALS AND METHODS: A randomized, cross-over, stratified sampling method was taken to divide the fourth-year undergraduate dental students equally into two groups. The two groups were crossed over to use VR and PPT. RESULTS: For the whole study, results indicated that students in the VR group showed higher learning motivation (including attention, relevance, confidence and satisfaction) than in the PPT group, but the differences between VR and PPT groups were not very big, and the median of the differences located at 0. For learning experience, students thought VR to be more useful, more enjoyable and more engaging, but the median of differences also located at 0. Notably, the majority of students had higher recommendations for VR than PPT, and the median difference located at 1. However, when the two phases were analysed separately, some items showed no significant differences between VR and PPT learning. CONCLUSION: VR is a very useful adjunct to education compared to traditional case analysis by PPT, but we cannot exaggerate its benefits. Educators should make good use of VR to solve the difficult problems in education.

Successful Reconstruction of Complex Sacrococcygeal Defects Using Chimeric Perforator Propeller Flap.

BACKGROUND: Complex soft tissue defects, which result from the surgical resection of sacral tumors, manifest as a combination of skin defects, dead space, infection, and prosthesis exposure. Because the traditional musculocutaneous flap lacks flexibility because of the close connection between the skin flap and the muscle component, the musculocutaneous flap is not suitable for reconstructing complex soft tissue defects where the dead space and skin defects are located at different sites. Furthermore, the perforator flap is also not appropriate for reconstructing complex defects because it lacks the muscular component. We considered the possibility of using the chimeric perforator propeller flap for reconstructing complex sacrococcygeal defects. METHODS: This study included 7 patients who underwent, between July 2007 and July 2021, the reconstruction of complex soft tissue defects of the sacrococcygeal region using a chimeric perforator propeller flap. RESULTS: Among the included cases, the etiologies were chordoma (n = 3), sacral tumor (n = 3), and squamous cell carcinoma (n = 1). In all the cases, vacuum-assisted closure therapy was used to treat wound infections before surgery. The average sizes of the skin and muscle flaps were 195.8 cm 2 (range, 100-350 cm 2 ) and 83.6 cm 2 (range, 60-140 cm 2 ), respectively. The superior gluteal artery was the source artery for the chimeric perforator propeller flap. The donor sites were primarily closed in all cases. One patient had delayed wound healing, and the secondary wound healed using conservative dressing changes. The other 6 flaps had no complications. The average follow-up time was 5.3 months (range, 1-9 months). Muscle weakness and compromised ambulation in the affected lower extremities were not observed in any of the patients. Furthermore, all 7 patients had no tumor recurrence, prosthesis exposure, and infection events in the sacrococcygeal region. CONCLUSIONS: The chimeric perforator propeller flap may be an option for reconstructing complex soft tissue defects in the sacrococcygeal region.

[Application of indocyanine green angiography in repair of facial soft tissue defect using superficial temporal artery based forehead flap].

Objective: To explore the feasibility of using indocyanine green angiography in mapping the superficial temporal vessels and assisting design and harvesting of the superficial temporal artery based forehead flap. Methods: A clinical data of 14 patients with facial soft tissue defects repaired with superficial temporal artery based forehead flaps between October 2015 and November 2022 was retrospectively analyzed. There were 9 males and 5 females with a median age of 9.5 years (range, 3-38 years). The forehead flaps were used to reconstruct facial soft tissue defects following excision of facial scar (8 cases) or congenital melanocyte nevus (6 cases). The size of defects ranged from 3 cm×2 cm to 24 cm×9 cm. Before operation, the indocyanine green angiography was used to map the superficial temporal artery and vein, and to analyze the relationship of the arteries and veins. The forehead flaps with unilateral superficial temporal fascia as the pedicle was transferred to repair the small facial defect in 2 cases. The facial pedicle contained the frontal branch of the superficial temporal artery and 2 cm of the superficial temporal fascia around the vessel, and the tiny accompanying vein of the frontal branch of the superficial temporal artery was used as the outflow of the flap. The forehead flaps with the skin pedicle including bilateral or unilateral superficial temporal fascia and the overlying skin was pre-expanded and transferred to repair the large facial defect in 12 cases. The skin pedicle contained the frontal branch of superficial temporal artery and one of main branches of superficial temporal vein. Among the 12 cases, the frontal branch of superficial temporal vein was used as the outflow in 4 cases, and the parietal branch was used as the outflow in 8 cases. The size of the flaps ranged from 3 cm×2 cm to 30 cm×13 cm. The skin pedicles were divided at 3 weeks after the flap transfer. Results: Indocyanine green angiography could clearly showed the course and branching of the superficial temporal artery and vein. Individual differences existed in the location where the frontal branch of the superficial temporal artery entered the forehead. The superficial temporal vein had great variability and did not follow the artery. One patient had expander-related complication, which resulted in 3-cm flap necrosis. The necrotic tissue was debrided and repaired with skin grafting. The other flaps totally survived and the incisions healed by first intention. All patients were followed up 2-24 months, with a median of 11.5 months. The color, texture, and thickness of the flaps matched well with those of recipient sites. Hypertrophic scar was not observed in recipient or donor site. All patients were satisfied with the reconstructive outcomes. Conclusion: Indocyanine green angiography can clearly visualize the course and the branches of the superficial temporal arteries and veins, which can help surgeons understand the position, distribution, and concomitant relationship of the superficial temporal vessels, and make a rational surgical plan of the forehead flap.

Extensive Defect Reconstruction With Pre-expanded Anterolateral Thigh Flap: Tissue Expansion of the "Outskirts".

BACKGROUND: Previously reported pre-expansion techniques of the anterolateral thigh flap are mainly perforator-based. The expansion will interfere with the flap harvest if the requisite perforator is found unsuitable as a pedicle. Expansion of the peripheral territories of the flap donor site can minimize the interference from the expansion. METHODS: Forty-eight peripheral pre-expansions of the anterolateral thigh flap were retrospectively reviewed in 38 patients from 2012 to 2021. The reconstructive outcomes, including flap success, increase in flap size, donor-site closure, and complications, were assessed. In addition, subgroup analysis was performed based on the expanded territories. RESULTS: Rate of successful flap elevation of 100% and flap survival rate of 97.9% were achieved. One patient had total flap necrosis, which was salvaged with skin grafting. Peripheral expansion attained a mean 55.5% ± 19.6% increase in flap width. Primary donor-site closure was accomplished in 95.8% of flaps and fascial restoration in 97.9% of the donor sites. Three patients developed major expansion-related complications, which required surgical intervention. One patient had wound dehiscence in the donor site, which healed by secondary intention. Compared with other subgroups, the lateral-and-medial-side expansion provided a larger flap for reconstruction (P = 0.001). CONCLUSIONS: If time is not of the essence, peripheral pre-expansion permits direct donor-site closure with size augment of the anterolateral thigh flap. In addition, it preserves the reliability and versatility of the anterolateral thigh flap.