Wide Local Excisions and Pedicled Perforator Flaps in Hidradenitis Suppurativa: A Study of Quality of Life.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic skin pathology characterized by the occurrence of inflamed and swollen lesions, with a devastating impact of the disease on patient's quality of life. Wide local excision (WLE) of the affected tissue is the criterion-standard treatment, but there is no general consensus on the best reconstructive technique. The aim of this article is to evaluate the quality of life before and after WLE combined with pedicled perforator flap reconstruction, in patients suffering from HS. METHODS: We analyzed 26 consecutive patients suffering from Hurley stage III HS. Every patient underwent WLE, followed by reconstruction with pedicled perforator flap. Dermatology Quality of Life Index (DLQI) tests were administered to every patient preoperatively and 6 months after surgery, when the clinical condition was considered stable. Dermatology Quality of Life Index scores were compared in terms of means with Student t test. Linear regression studies were used to compare the changes in DLQI score with the surgical and clinical variables. RESULTS: Axillary area involvement was found in 21 of 27 patients; 6 patients had more than 1 body region involved. Thirty-two pedicled perforator flaps were performed, and 22 were thoracodorsal artery perforator flaps. Mean DLQI test score before the first operation was 21.31 ± 4.79; the average DLQI score after the last follow-up was 5 ± 2.95 (P < 0.0001). Dermatology Quality of Life Index scores were not influenced by complications including reoperation. There were also no correlations found between DLQI score delta and number of reoperation (-0.18) or days of hospital stay (-0.13). CONCLUSIONS: Wide local excision followed by pedicled perforator flap reconstruction allows a radical excision of HS areas with short postoperative healing periods. Dermatology Quality of Life Index scores confirmed high levels of patients' satisfaction. Disadvantages of this technique include difficult learning curve, long operating time, and a nonnegligible complications rate.

Robustness Testing of Mesenchymal Stem Cell Monotherapy Following Vascularized Composite Allotransplantation.

BACKGROUND: Immunosuppression risks are a major concern with vascularized composite allotransplantation (VCA). As an emerging strategy, the antirejection role played by mesenchymal stem cells (MSCs) is receiving attention. However, the current literature reports are inconclusive regarding the robustness of the MSC monotherapy. Using a rat forelimb VCA model, this study tested the robustness of the immunomodulation efficacy of gingival-derived MSCs (GMSCs) and bone marrow-derived MSCs (BMMSCs). METHODS: Forelimbs were transplanted on pairs of major histocompatibility complex-incompatible rats (Wistar-Kyoto donor, Lewis [LEW] recipient). Twenty-four LEW rats were randomly divided into four groups, including control (no treatment) and three treatment groups: rapamycin (2 mg/kg/day for 28 days, postoperatively), BMMSC and GMSC, both of which received donor-derived stem cells administered intravenously on postoperative days (PODs) 0, 3, 7, and 14. Rejection was considered as 80% skin necrosis of the allograft. Microcomputed tomography (µCT) was performed to evaluate healing at osteosynthesis site. On POD 14, limbs from each group underwent histological analysis and rejection grading using the Banff system. RESULTS: Both BMMSC (15.0 days) and GMSC (14.7 days) treatment failed to prolong VCA survival in comparison with the control group (13.8 days; p > 0.050), while the rapamycin significantly delayed acute VCA rejection (24.5 days; p = 0.003). Micro-CT imaging revealed no gross visual difference across all groups. Histology revealed that the control group was most severely affected (grades III and IV) followed by MSC (grade II) and rapamycin (grade I). CONCLUSION: MSC monotherapy, both BMMSC and GMSC, did not inhibit rejection in our VCA model. Skin immunogenicity is an important issue in promoting rejection, and a concomitant immunosuppression regimen should be considered to prolong allograft survival.

The Effect of Muscle Exercise on Perforators Flow: A Prospective Cohort Study.

Background and objectives: The metabolic response after exercise causes a significant increase in the muscle blood flow. While these effects are demonstrated for intra-muscular vessels, there is no evidence about the inter-muscular vessels, such as the septocutaneous perforators supplying the skin after they branch out from the deep source artery. The aim of our prospective study was to quantify the changes in the anterior tibial artery perforators arterial blood flow after mild isotonic exercise in a young and healthy population. Material and Methods: We performed a prospective analysis of 34 patients who were admitted to the Plastic Surgery Department from December 2019 to April 2020. Flow velocities of two previously identified anterior tibial artery perforators were recorded both before and after 10 complete flexion-extensions of the foot. The time to revert to basal flow was measured. We further classified the overmentioned patients based on their level of physical activity. Results: We registered a significant increase in systolic, diastolic and mean blood flow velocities both in proximal and distal anterior tibial artery perforators after exercise. Fitter patients exhibited a higher increase in proximal leg perforators than those who did less than three aerobic workouts a week. The time to return to basal flow ranged from 60 to 90 s. Conclusions: This was the first study to describe the effect of muscular activity on perforators blood flow. Even mild exercise significantly increases the perforator flow. Waiting at least two minutes at rest before performing the Doppler study, thus avoiding involved muscle activation, can notably improve the reliability of the pre-operative planning.

Supercharging Strategies for Prefabricated Flaps in a Rat Model.

BACKGROUND: Limited survival area is an intractable problem in the clinical practice of prefabricated flaps. This study compared four strategies to find an effective method and to understand the potential mechanisms for supercharging. METHODS: A prefabricated abdominal flap rodent model was prepared. Rats were randomly divided into five groups (n = 6/group). (A) Control group: prefabricated right side femoral vessels. Based on group A, various prefabricated vessels were added; (B) proximal venous supercharging group: right side superficial inferior epigastric vein (SIEV); (C) proximal arterial supercharging group: right side superficial inferior epigastric artery (SIEA); (D) distal venous supercharging group: left side SIEV; and (E) distal arterial supercharging group: left side SIEA. Macroscopic analysis, near-infrared fluorescence imaging, and microscopy were used to analyze the survival area, fluorescence area, and capillary density. RESULTS: No significant differences in survival areas were found among supercharging groups (B-E), which were larger than in the control group. Near-infrared fluorescence imaging showed the areas of control and venous supercharging groups (A, B, and D) were smaller than in arterial groups (C and E). Capillary density areas in the right part of the flap in proximal supercharging groups (B and C) and left part of the flap in distal supercharging groups (D and E) were all greater than group A, with no significant differences among the other groups. CONCLUSION: Enhanced neovascularization is a useful supercharging strategy. Both arterial and venous vessel supercharging improved the survival area of prefabricated flaps.

Upper and lower extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: A systematic review.

BACKGROUND: Free flaps derived from the medial genicular artery (MGA) system, including the medial femoral condyle (MFC) and medial femoral trochlear (MFT) flaps, are potential reconstructive options to address upper and lower extremity bony pathology. Our primary aim was to comprehensively search the literature to describe the spectrum of pathology treated with these flaps, and to assess patient outcomes to improve our understanding of expected union and complication rates. METHODS: Following PRISMA guidelines, a systematic review using Pubmed and Embase databases with citation cross-referencing was performed to identify all original clinical articles characterizing MGA flap treatment of upper and lower extremity pathology. RESULTS: The initial search identified 173 articles which was narrowed down to 40 meeting inclusion criteria, representing a total of 248 cases: 174 and 74 in the upper and lower extremities, respectively. Sixteen distinct recipient sites were identified with union rates ranging from 66 to 100% (98.7% overall). The majority (83.9%) of patients had undergone prior failed surgery. Major complications (those with limb/flap loss or requiring unplanned reoperation) were more frequent for lower versus upper extremity applications (17.1% vs. 6.2%, respectively). Donor site femoral fracture or persistent knee dysfunction occurred in 0.8% and 0.4% of patients, respectively. CONCLUSIONS: MGA free flaps are a versatile option for upper and lower extremity osseous reconstruction, offering high rates of union with minimal complications for a complex patient population. This study furthers our understanding of patient outcomes following MGA flap reconstruction, which previously was limited to case reports and small case series.

Elbow vascularized composite allotransplantation-surgical anatomy and technique.

BACKGROUND: Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA. METHODS: We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique. RESULTS: The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs. CONCLUSIONS: Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique.

Prefabricated Flaps: Identification of Microcirculation Structure and Supercharging Technique Improving Survival Area.

Background Microcirculation is an important factor frequently overlooked when studying the survival of prefabricated flaps. In the current study, we use different prefabrication techniques for characterizing microcirculation within the flap, with the goal of finding an effective way to improve its survival area. Methods An abdominal prefabricated flap rodent model was created using a two-stage operation. All rats were randomly divided into six groups (n = 10/group): group A, prefabricated femoral vessels; group B, prefabricated femoral artery with a connected superficial inferior epigastric vein (SIEV); group C, connected superficial inferior epigastric artery (SIEA) with a prefabricated femoral vein; group D was similar to group A along with a prefabricated SIEA, and group E was similar to group A along with a prefabricated SIEV; and group F acted as a control group and consisted of an axial flap nourished by superficial inferior epigastric vessels. Flaps were assessed for survival area, blood perfusion area, and capillary density using macroscopic analysis, near-infrared fluorescence imaging (NIFI), and histology. Results The survival area was not significantly different when comparing groups B to C, and D to E. The survival area of groups D and E was larger than that of groups B and C. Groups B through E had a smaller survival area in comparison to group F and a larger survival area than group A. NIFI were consistent with the macroscopic outcomes. The capillary density was not significantly different between groups A to C and groups D to F. Conclusion Both arterial and venous supercharging could potentially improve the survival area of prefabricated flaps.

Ex Vivo Delay: A Novel Approach to Increase Prefabricated Flaps Survival Rate.

Background Limited flap survival area is the main disadvantage of prefabricated flaps. To deal with this problem, surgical delay is the common method to achieve a better prognosis. This method requires multiple surgeries with the known associated burdens. We have developed a new strategy, ex vivo delay, utilizing the pathophysiology of surgical delay while avoiding the need for multiple surgeries. Methods We created a rodent animal model utilizing a two-stage operation of a prefabricated abdominal flap. The rats were randomly divided into three groups (n = 6 per group): group A, the control group (no intervention), group B, delayed by the ex-vivo delay device, and group C, delayed using surgical delay technique. Data were collected according to macroscopic analysis, near-infrared fluorescence imaging, and capillary densities. Results According to the macroscopic analysis, groups B and C had a significantly larger flap survival area compared with group A, but group B had a significantly smaller survival area than group C. The near-infrared fluorescence imaging showed the perfusion areas of group B and C to be larger than that of group A. Histologically, groups B and C had a significantly higher capillary density than group A. The vessel caliber in group C was larger than that of groups A and B. Conclusions The ex vivo delay strategy successfully increased flap survival area. This strategy worked by establishing ischemia and enhancing neovascularization. Further improvements in the surgical technique could produce outcomes similar to those seen with surgical delay.

Preliminary Exploration: When Angiosome Meets Prefabricated Flaps.

Background The best known limitation to the use of prefabricated flaps is their limited survival area. One explanation for this is insufficient neovascularization. However, blood flow of prefabricated flaps is through their innate vascular network. This could lead one to conclude that angiosomes may impede blood perfusion. This study aims to settle this contradiction between theory and clinical practice. Methods We performed a two-stage operation of a prefabricated abdominal flap in a rat model. The rats were divided into five groups (n = 6/group). Group A: fixed pedicle at a horizontal angle; Group B: fixed pedicle at an oblique angle; Group C: fixed pedicle at a vertical angle; Group D: fixed pedicle in the same position as Group A; and Group E: axial flap. Groups A and B were prefabricated for 2 weeks and Groups C and D were prefabricated for 3 weeks. Macroscopic appearance was noted, and analysis of near-infrared fluorescence imaging and capillary density was performed. Results There was no significant difference in the flaps' survival area between Groups A and B. Group D had a significantly larger survival area when compared with Group C. The boundary between two angiosomes (medioventral line) seemed to limit the indocyanine green perfusion in Groups B, C, and E, while in Groups A and D, no such limitation was seen. Capillary density was positively correlated with neovascularization time. Conclusions Angiosomes impede blood perfusion in prefabricated flaps. Cross-bound neovascular vessels nourish the flap, thus overcoming the limitation of choke vessels.

Turnover Tendon Lengthening Does Not Alter Biomechanical Strength of Pronator Teres-to-Extensor Carpi Radialis Brevis Tendon Transfer.

BACKGROUND: The pronator teres (PT) to extensor carpi radialis brevis (ECRB) tendon transfer reestablishes wrist extension. Occasionally, the PT periosteal extension is of suboptimal quality to support a strong transfer. In these instances, turnover lengthening techniques can increase usable tendon length. This study characterized the optimal length of tendon turnover and the effect of lengthening on transfer strength. METHODS: Twenty-seven cadaveric extensor tendons were lengthened using the turnover lengthening technique with 1 to 3 cm of tendon overlap. PT-to-ECRB tendon transfers were performed with native or lengthened ECRB tendons. Tensile testing was used to evaluate stress relaxation and load to failure. RESULTS: The median maximum load to failure increased with increasing overlap length, measuring 35.6 N (quartile 1, 30.2 N; quartile 3, 38.6 N) for 1 cm, 66.0 N (quartile 1, 59.1 N; quartile 3, 74.7 N) for 2 cm, and 96.6 N (quartile 1, 85.9; quartile 3, 114.9 N) for 3 cm of overlap ( P < 0.05). Failure occurred most frequently at the junction of the central overlap and native tendon. Tendons lengthened with 2 and 3 cm of overlap displayed greater stiffness than those with 1 cm ( P < 0.05). Lengthening the ECRB tendon with 2 or 3 cm of overlap did not disrupt the strength or stiffness of subsequent PT-to-ECRB tendon transfers. CONCLUSIONS: Turnover tendon lengthening does not detrimentally affect PT-to-ECRB tendon transfer. Greater overlap lengthening distance confers greater stiffness and resistance to rupture. When the periosteal extension of the PT tendon avulses or is of poor quality, the ECRB tendon can be lengthened using the turnover tendon lengthening technique to facilitate a robust transfer.

Orthoplastic Approach to Lower Extremity Reconstruction: An Update.

In order to address complex extremity injuries, the orthoplastic approach uses plastic, orthopedic, and microsurgical techniques and includes other disciplines to optimize limb salvage. This collaboration, if created early in treatment, allows for more expedient and individualized solutions to a variety of extremity injuries resulting in decreased hospital stay, fewer complications, and improved functional outcomes. The orthoplastic approach does not merely avoid amputation, but also improves patient function and quality of life in the short and long term.

Ultramobile Surgical Set for Austere Damage Control Surgery.

The authors describe an equipment list for an ultramobile, surgeon-carried equipment set that is specifically designed for missions that require the extremes of constraints on personnel and resources conducted outside the ring of golden hour access to damage control surgery (DCS) capabilities.

Limited efficacy of rapamycin monotherapy in vascularized composite allotransplantation.

BACKGROUND: Vascularized composite allotransplantation (VCA) is a novel and life-enhancing procedure to restore a patient's function and/or appearance. Current immunosuppression in VCA recipients is based on calcineurin inhibitor (CNI) therapy that can lead to severe complications, such that inducing immune tolerance is a major goal of VCA research. In contrast to CNI, rapamycin (RPM) is thought to be beneficial to the development of immune tolerance by suppressing T-effector cells (Teffs) and expanding T-regulatory (Treg) cells. However, we found high dose RPM monotherapy prolonged VCA survival by only a few days, leading us to explore the mechanisms responsible. METHODS: A mouse orthotopic forelimb transplantation model (BALB/c- > C57BL/6) was established using WT mice, as well as C57BL/6 recipients with conditional deletion of T-bet within their Treg cells. Events in untreated VCA recipients or those receiving RPM or FK506 therapy were analyzed by flow-cytometry, histopathology and real-time qPCR. RESULTS: Therapy with RPM (2 mg/kg/d, p < .005) or FK506 (2 mg/kg/d, p < .005) each prolonged VCA survival. In contrast to FK506, RPM increased the ratio of splenic Treg to Teff cells (p < .05) by suppressing Teff and expanding Treg cells. While the proportion of activated splenic CD4 + Foxp3- T cells expressing IFN-γ were similar in control and RPM-treated groups, RPM decreased the proportions ICOS+ and CD8+ IFN-γ + splenic T cells. However, RPM also downregulated CXCR3+ expression by Tregs, and forelimb allografts had reduced infiltration by CXCR3+ Treg cells. In addition, allograft recipients whose Tregs lacked T-bet underwent accelerated rejection compared to WT mice despite RPM therapy. CONCLUSIONS: We demonstrate that while RPM increased the ratio of Treg to Teff cells and suppressed CD8+ T cell allo-activation, it failed to prevent CD4 Teff cell activation and impaired CXCR3-dependent Treg graft homing, thereby limiting the efficacy of RPM in VCA recipients.