Cost-Effectiveness of Hepatitis E Vaccination Strategies among Patients with Chronic Liver Diseases in China: A Model-Based Evaluation.

Hepatitis E virus (HEV) is a leading cause of acute viral hepatitis worldwide, primarily transmitted through contaminated water and food. In patients with chronic liver disease (CLD), HEV infection might worsen the prognosis. This study aimed to evaluate the cost-effectiveness of hepatitis E vaccination strategies in CLD patients. A decision tree-Markov cohort model was used to assess the cost-effectiveness of universal-vaccination, vaccination-following-screening, and no-vaccination strategies in 100,000 CLD patients over their lifetimes, simulating cohorts aged ≥16 years, ≥40 years, and ≥60 years, based on the licensed vaccination ages and typical ages of CLD onset, from a societal perspective. Model parameters were retrieved and estimated from previous publications and government data. The outcomes included HEV-related cases, costs, and the incremental cost-effectiveness ratio (ICER). Compared to no-vaccination, universal-vaccination reduced HEV-related cases by 32.8% to 39.6%, while vaccination-following-screening reduced them by 38.1% to 49.3%. Furthermore, universal-vaccination showed ICERs of USD 6898.33, USD 6638.91, and USD 6582.69 per quality-adjusted life year (QALY) for cohorts aged ≥16, ≥40, and ≥60 years, respectively. Moreover, the vaccination-following-screening strategy significantly enhanced cost-effectiveness, with ICERs decreasing to USD 6201.55, USD 5199.46, and USD 4919.87 per QALY for the cohorts. Additionally, one-way sensitivity analysis identified the discount rate and utility for CLD patients as the key factors influencing ICER. Probabilistic sensitivity analysis indicated the vaccination-following-screening strategy was cost-effective with probabilities of 92.50%, 95.70%, and 95.90% for each cohort. Hepatitis E vaccination in CLD patients costs less than GDP per capita for each QALY gained in China. The vaccination-following-screening strategy may be the optimal option, especially in those over 60 years.

Effectiveness of Core Excision Technique for Keloids: A Systematic Review.

BACKGROUND: The keloid core excision technique mitigates the risk of wound tension and promotes favorable morphological outcomes. However, whether residual keloid tissue or other factors increase the risk of recurrence remains unclear. This systematic review aimed to evaluate the therapeutic outcomes of core excision techniques for keloids. METHODS: A systematic literature review was conducted by searching PubMed, Embase, Web of Science Core Collection, and Cochrane Library databases on July 30, 2023. The search terms employed were "keloid," "core excision," "intralesional excision," "intramarginal excision," "rind flap," and "fillet flap." The inclusion criteria for the studies were established in advance and evaluated by multiple investigators. RESULTS: Overall, 20 studies involving 926 keloid cases managed through core excision were included. Adjuvant therapies were used in 19 studies, with radiotherapies and steroid injections emerging as the predominant methods. The recurrence rates ranged from 0% to 28.6%. Residual scar tissue after core excision and complications, such as flap necrosis and hematoma, are the major factors contributing to recurrence. CONCLUSION: The core excision technique is a surgical treatment of keloids with a low recurrence rate when combined with adjuvant therapies. However, randomized controlled trials and conclusive quantitative studies are necessary to further investigate the effects of the core excision technique on keloids.

Accurate brain pharmacokinetic parametric imaging using the blood input function extracted from the cavernous sinus.

Brain pharmacokinetic parametric imaging based on dynamic positron emission tomography (PET) scan is valuable in the diagnosis of brain tumor and neurodegenerative diseases. For short-axis PET system, standard blood input function (BIF) of the descending aorta is not acquirable during the dynamic brain scan. BIF extracted from the intracerebral vascular is inaccurate, making the brain parametric imaging task challenging. This study introduces a novel technique tailored for brain pharmacokinetic parameter imaging in short-axis PET in which the head BIF (hBIF) is acquired from the cavernous sinus. The proposed method optimizes the hBIF within the Patlak model via data fitting, curve correction and Patlak graphical model rewriting. The proposed method was built and evaluated using dynamic PET datasets of 67 patients acquired by uEXPLORER PET/CT, among which 64 datasets were used for data fitting and model construction, and 3 were used for method testing; using cross-validation, a total of 15 patient datasets were finally used to test the model. The performance of the new method was evaluated via visual inspection, root-mean-square error (RMSE) measurements and VOI-based accuracy analysis using linear regression and Person's correlation coefficients (PCC). Compared to directly using the cavernous sinus BIF directly for parameter imaging, the new method achieves higher accuracy in parametric analysis, including the generation of Patlak plots closer to the standard plots, better visual effects and lower RMSE values in the Ki (P = 0.0012) and V (P = 0.0042) images. VOI-based analysis shows regression lines with slopes closer to 1 (P = 0.0019 for Ki ) and smaller intercepts (P = 0.0085 for V). The proposed method is capable of achieving accurate brain pharmacokinetic parametric imaging using cavernous sinus BIF with short-axis PET scan. This may facilitate the application of this imaging technology in the clinical diagnosis of brain diseases.

Angiosome-Guided Perfusion Decellularization of Fasciocutaneous Flaps.

BACKGROUND: Tissue engineering based on whole-organ perfusion decellularization has successfully generated small-animal organs, including the heart and limbs. Herein, we aimed to use angiosome-guided perfusion decellularization to develop an acellular fasciocutaneous flap matrix with an intact vascular network. METHODS: Abdominal flaps of rats were harvested, and the vascular pedicle (iliac artery and vein) was dissected and injected with methylene blue to identify the angiosome region and determine the flap dimension for harvesting. To decellularize flaps, the iliac artery was perfused sequentially with 1% sodium dodecyl sulfate (SDS), deionized water, and 1% Triton-X100. Gross morphology, histology, and DNA quantity of flaps were then obtained. Flaps were also subjected to glycosaminoglycan (GAG) and hydroxyproline content assays and computed tomography angiography. RESULTS: Histological assessment indicated that cellular content was completely removed in all flap layers following a 10-hour perfusion in SDS. DNA quantification confirmed 81% DNA removal. Based on biochemical assays, decellularized flaps had hydroxyproline content comparable with that of native flaps, although significantly fewer GAGs (p = 0.0019). Histology and computed tomography angiography illustrated the integrity and perfusability of the vascular system. CONCLUSION: The proposed angiosome-guided perfusion decellularization protocol could effectively remove cellular content from rat fasciocutaneous flaps and preserve the integrity of innate vascular networks.

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.

Interactive model for predicting the oncological outcome of patients with early-stage huge hepatocellular carcinoma after hepatectomy: a multicenter population-based study.

An interactive model for predicting the oncological outcome of patients with early-stage huge hepatocellular carcinoma (ES-HHCC) after hepatectomy is still lacking. This study was aimed at exploring the independent risk parameters and developing an interactive model for predicting the cancer-specific survival (CSS) of ES-HHCC. Data from patients with ES-HHCC who underwent hepatectomy were collected. The dimensionality of the clinical features was reduced by least absolute shrinkage and selection operator regression and further screened as predictors of CSS by Cox regression. Then, an interactive prediction model was developed and validated. Among the 514 screened patients, 311 and 203 of them were assigned into the training and validation cohort, respectively. Six independent variables, including alpha-fetoprotein, cirrhosis, microvascular invasion, satellite, tumor morphology, and tumor diameter, were identified and incorporated into the prediction model for CSS. The model achieved C-indices of 0.724 and 0.711 in the training and validation cohorts, respectively. Calibration curves showed general consistency in both cohorts. Compared with single predictor, the model had a better performance and greater benefit according to the time-independent receiver operating characteristic curve and decision curve analysis (P < 0.05). The calculator owned satisfactory accuracy and flexible operability for predicting the CSS of ES-HHCC, which could serve as a practical tool to stratify patients with different risks, and guide decision-making.

Learning CT-free attenuation-corrected total-body PET images through deep learning.

OBJECTIVES: Total-body PET/CT scanners with long axial fields of view have enabled unprecedented image quality and quantitative accuracy. However, the ionizing radiation from CT is a major issue in PET imaging, which is more evident with reduced radiopharmaceutical doses in total-body PET/CT. Therefore, we attempted to generate CT-free attenuation-corrected (CTF-AC) total-body PET images through deep learning. METHODS: Based on total-body PET data from 122 subjects (29 females and 93 males), a well-established cycle-consistent generative adversarial network (Cycle-GAN) was employed to generate CTF-AC total-body PET images directly while introducing site structures as prior information. Statistical analyses, including Pearson correlation coefficient (PCC) and t-tests, were utilized for the correlation measurements. RESULTS: The generated CTF-AC total-body PET images closely resembled real AC PET images, showing reduced noise and good contrast in different tissue structures. The obtained peak signal-to-noise ratio and structural similarity index measure values were 36.92 ± 5.49 dB (p < 0.01) and 0.980 ± 0.041 (p < 0.01), respectively. Furthermore, the standardized uptake value (SUV) distribution was consistent with that of real AC PET images. CONCLUSION: Our approach could directly generate CTF-AC total-body PET images, greatly reducing the radiation risk to patients from redundant anatomical examinations. Moreover, the model was validated based on a multidose-level NAC-AC PET dataset, demonstrating the potential of our method for low-dose PET attenuation correction. In future work, we will attempt to validate the proposed method with total-body PET/CT systems in more clinical practices. CLINICAL RELEVANCE STATEMENT: The ionizing radiation from CT is a major issue in PET imaging, which is more evident with reduced radiopharmaceutical doses in total-body PET/CT. Our CT-free PET attenuation correction method would be beneficial for a wide range of patient populations, especially for pediatric examinations and patients who need multiple scans or who require long-term follow-up. KEY POINTS: • CT is the main source of radiation in PET/CT imaging, especially for total-body PET/CT devices, and reduced radiopharmaceutical doses make the radiation burden from CT more obvious. • The CT-free PET attenuation correction method would be beneficial for patients who need multiple scans or long-term follow-up by reducing additional radiation from redundant anatomical examinations. • The proposed method could directly generate CT-free attenuation-corrected (CTF-AC) total-body PET images, which is beneficial for PET/MRI or PET-only devices lacking CT image poses.

Molecular epidemiology and phylogeny of the emerging zoonotic virus Rocahepevirus: A global genetic analysis.

Human infections with Rocahepevirus ratti genotype C1 (HEV-C1) in Hong Kong of China, Canada, Spain, and France have drawn worldwide concern towards Rocahepevirus. This study conducted a global genetic analysis of Rocahepevirus, aiming to furnish comprehensive molecular insights and promote further research. We retrieved 817 Rocahepevirus sequences from the GenBank database through October 31, 2023, categorizing them according to research, sample collection area and date, genotype, host, and sequence length. Subsequently, we conducted descriptive epidemiological, phylogenetic evolutionary, and protein polymorphism (in length and identity) analyses on these sequences. Rocahepevirus genomes were identified across twenty-eight countries, predominantly in Asia (71.73%, 586/817) and Europe (26.44%, 216/817). The HEV-C1 dominates Rocahepevirus (77.2%, 631/817), while newly discovered Rocahepevirus genotypes (C3/C4/C5 and other unclassified genotypes) were primarily identified in Europe (25/120) and China (91/120). Muridae animals (72.5%, 592/817) serve as the primary hosts for Rocahepevirus, with other hosts encompassing species from the families Soricidae, Hominidae, Mustelidae, and Cricetidae. Additionally, Rocahepevirus genomes (C1 genotype) were identified in sewage samples recently. The phylogenetic evolution of Rocahepevirus exhibits considerable variation. Specifically, HEV-C1 can be classified into at least six genetic groups (G1 to G6), with human HEV-C1 distributed across multiple evolutionary clades. The overall ORF1 and ORF2 amino acid sequence lengths were significantly different (P < 0.001) across Rocahepevirus genotypes. HEV-C1/C2/C3 and HEV-C4/C5 displayed substantial differences in amino acid sequence identity (58.4%-59.6%). The identification of Rocahepevirus genomes has expanded across numerous countries, particularly in European and Asian countries, coinciding with an expanding host range and emergence of new genotypes. The evolutionary path of Rocahepevirus is intricate, where the HEV-C1 dominates globally and internally forms multiple evolutionary groups (G1 to G6), exhibiting diverse genetic variation within human HEV-C1. Significant differences exist in the protein polymorphism (in length and identity) across Rocahepevirus genotypes. Given Rocahepevirus's shift from an animal virus to a zoonotic pathogen, worldwide cooperation in monitoring Rocahepevirus genomes is vital.

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.

RBM10 regulates the tumorigenic potential of human cancer cells by modulating PPM1B and YBX1 activities.

RNA binding protein RBM10 participates in various RNA metabolism, and its decreased expression or loss of function by mutation has been identified in many human cancers. However, how its dysregulation contributes to human cancer pathogenesis remains to be determined. Here, we found that RBM10 expression was decreased in breast tumors, and breast cancer patients with low RBM10 expression presented poorer survival rates. RBM10 depletion in breast cancer cells significantly promotes the cellular proliferation and migration. We further demonstrated that RBM10 forms a triple complex with YBX1 and phosphatase 1B (PPM1B), in which PPM1B serves as the phosphatase of YBX1. RBM10 knock-down markedly attenuated association between YBX1 and PPM1B, leading to elevated levels of YBX1 phosphorylation and its nuclear translocation. Furthermore, cancer cells with RBM10 depletion had a significantly accelerated tumor growth in nude mice. Importantly, these enhanced tumorigenic phenotypes can be reversed by overexpression of PPM1B. Our findings provide the mechanistic bases for functional loss of RBM10 in promoting tumorigenicity, and are potentially useful in the development of combined therapeutic strategies for cancer patients with defective RBM10.

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.

LCRNet: local cross-channel recalibration network for liver cancer classification based on CT images.

Liver cancer is the leading cause of mortality in the world. Over the years, researchers have spent much effort in developing computer-aided techniques to improve clinicians' diagnosis efficiency and precision, aiming at helping patients with liver cancer to take treatment early. Recently, attention mechanisms can enhance the representational power of convolutional neural networks (CNNs), which have been widely used in medical image analysis. In this paper, we propose a novel architectural unit, local cross-channel recalibration (LCR) module, dynamically adjusting the relative importance of intermediate feature maps by considering the roles of different global context features and building the local dependencies between channels. LCR first extracts different global context features and integrates them by global context integration operator, then estimates per channel attention weight with a local cross-channel interaction manner. We combine the LCR module with the residual block to form a Residual-LCR module and construct a deep neural network termed local cross-channel recalibration network (LCRNet) based on a stack of Residual-LCR modules to recognize live cancer atomically based on CT images. Furthermore, This paper collects a clinical CT image dataset of liver cancer, AMU-CT, to verify the effectiveness of LCRNet, which will be publicly available. The experiments on the AMU-CT dataset and public SD-OCT dataset demonstrate our LCRNet significantly outperforms state-of-the-art attention-based CNNs. Specifically, our LCRNet improves accuracy by over 11% than ECANet on the AMU-CT dataset. Supplementary Information: The online version contains supplementary material available at 10.1007/s13755-023-00263-6.

[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.

[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.

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.