Antecubital Fossa Perforator Flaps for Soft-Tissue Defect Repair of the Anterior Elbow: Anatomical Study and Clinical Application.

BACKGROUND: The antecubital fossa is a main perforator cluster region located beside the anterior elbow defect, rendering it crucial to harvest the perforator pedicled flaps for the anterior elbow defects. PATIENTS AND METHODS: A total of 30 preserved cadaveric forearms were dissected in order to describe the perforator anatomy in the antecubital fossa. For each perforator, the number, the site of origin, the diameter at its origin, and the trajectory were recorded. In addition, all the patients treated for anterior elbow defects using inferior cubital artery (ICA) perforator pedicled flaps between June 2013 and June 2018 were reviewed in this retrospective study. RESULTS: A total of 85 perforators were dissected in the antecubital fossa area from the 30 specimens. Among these, 65 perforators originated from the radial artery, 6 from the recurrent radial artery, 13 from the brachial artery, and 1 from the ulnar artery. Each forearm specimen had a constant and large ICA perforator. All perforators originated from source vessels 2-5 cm distal from the interepicondylar line and could be harvested as perforator pedicled flap for anterior elbow reconstruction. In the clinical study, 11 patients with anterior elbow defects were treated with ICA perforator pedicled flaps with satisfactory functional and aesthetic outcomes. CONCLUSION: The antecubital fossa has a constant and dominant ICA perforator and many other perforators. The pedicled antecubital fossa perforator flaps could be harvested flexibly with a reliable blood supply for anterior elbow reconstruction.

Reconstruction of Large Cervicofacial Defects With Expanded Island Superficial Temporal Artery Flaps and an 810-nm Diode Laser Hair Removal Technique.

BACKGROUND: Extensive cervicofacial reconstruction is challenging for plastic surgeons. Because of the location of the adjacent scalp flap nourished by the superficial temporal artery (STA), it can be a candidate for cervicofacial reconstruction. OBJECTIVES: This article aims to report a combined treatment of an expanded island STA flap and an 810-nm diode laser hair removal technique for extensive cervicofacial defects. METHODS: Between January 2015 and December 2018, 10 patients with lower face and neck scar contraction were reconstructed with a bilateral or unilateral expanded STA island flap and an 810-nm diode laser for hair removal in this retrospective study. Hair removal via the 810-nm laser was started when the injected volume reached the volume of the expander, with a fluence of 35 to 40 J/cm2 and a 1 to 2 Hz repetition rate. Before second-stage surgery, the hair reduction rate was assessed. Twelve months after surgery, the degree of epilation efficacy according to the satisfaction scale and Global Aesthetic Improvement Scale was evaluated. RESULTS: This study included 2 single-pedicle flaps and 8 double-pedicle flaps. The average size of the implanted expanders was 600 mL. The average injected volume was 1405 mL. Before second surgery, there was a 67.4% hair reduction rate. Twelve months after surgery, the results of Global Aesthetic Improvement Scale were very good (3), good (6), average (1), and poor (0). CONCLUSIONS: The expanded island STA flap and 810-nm diode laser technique may be a novel treatment option for severe face and neck aesthetic reconstruction.

Inhibition of CUB and sushi multiple domains 1 (CSMD1) expression by miRNA-190a-3p enhances hypertrophic scar-derived fibroblast migration in vitro.

BACKGROUND: Hypertrophic scar (HTS) is a fibroproliferative skin disorder characterized by excessive cell proliferation, migration, and extracellular matrix (ECM) deposition. The CUB and Sushi multiple domains 1 (CSMD1) has previously been identified as the key regulatory gene of hypertrophic scar by a large sample GWAS study. However, further research has not yet been conducted to verify this finding in other HTS patients and to determine the underlying mechanism. RESULTS: In this study, we verified that CSMD1 was downregulated in both HTS tissue and HTS-derived fibroblasts. The knockdown of CSMD1 resulted in enhanced migration and fibronectin1 (FN1) secretion in fibroblasts in vitro. In addition, the upstream and downstream regulatory mechanisms of CSMD1 were also investigated through microRNA (miRNA) databases screening and RNA-sequencing (RNA-seq) respectively. The screening of four common microRNA (miRNA) databases suggested that miR-190a-3p binds to the CSMD1 and may regulate its expression. We confirmed that miR-190a-3p directly targeted the CSMD1-3'-UTR using luciferase reporter assays. Furthermore, the overexpression of miR-190a-3p showed promotion of migratory activity and FN1 secretion in fibroblasts, resembling the effect of CSMD1 knockdown; whereas the knockdown of miR-190a-3p exerted the opposite effect. Finally, transcriptomic analysis showed activation of Janus kinase-signal transducer and activator of transcription (JAK/STAT) signaling pathway in the CSMD1 knockdown fibroblasts. CONCLUSIONS: This study has validated the conclusions of the previous GWAS study conducted in Chinese population. In vitro experiments have provided further evidence on the function of CSMD1 in the development of HTS, and have also revealed the underlying upstream and downstream regulating mechanisms. Additionally, the JAK/STAT signaling pathway identified using RNA-seq might provide a potential treatment approach, especially for HTS.

Modified Anterior Tibial Artery Perforator-Pedicled Propeller Flap for Soft-Tissue Coverage of the Ankle and Heel.

BACKGROUND: The ankle and heel are challenging regions to reconstruct functionally. Here, we explored the feasibility and clinical outcomes of a modified anterior tibial artery perforator-pedicled propeller flap for the repair of soft-tissue defects of the ankle and heel. PATIENTS AND METHODS: Between January 2013 and December 2015, 12 patients with soft-tissue defects of the ankle and/or heel underwent reconstructive surgery that included our flap technique. The flaps measured 20 × 8 cm to 7 × 4 cm. A hand-held Doppler was used to identify a proper constant perforator in the distal ankle. In each case, the base of the flap was well preserved. The flap was transposed (180° rotation) to reach and cover the defect. RESULTS: The average follow-up time was 13 months (10-28 months). We observed good texture matches and contour in all of the flaps. All patients could walk and wear normal footwear. All but one flap survived completely without complications. Partial loss was observed in one patient, and the necrotic region was healed with secondary intention. CONCLUSION: Our modified anterior tibial artery free-style perforator-pedicled propeller flap provides a novel option for functional ankle and heel reconstruction. LEVEL OF EVIDENCE: Level IV.

Postburn Neck Reconstruction With Preexpanded Upper Back Perforator Flaps: Free-Style Design and An Update of Treatment Strategies.

BACKGROUND: For extensive postburn neck deformities, the preexpanded flaps in the upper back region were used and gained a uniform skin appearance and esthetic contours. Free-style perforator-based free-tissue transfer that represents the most recent advance in reconstructive surgery may provide more versatility of these flaps. METHODS: We retrospectively reviewed 31 patients treated at our institution for postburn neck contracture from March 2010 to May 2016. Various upper back flaps were designed according to the dominant perforators and the shape of the defect after fully releasing the neck contracture. RESULTS: Thirty-one patients received neck reconstructions with the versatile applications of the preexpanded upper back perforator flaps. Tip necrosis was observed in one case, and the others survived completely. The donor sites were all primarily closed. No incision dehiscence was observed. CONCLUSION: The free-style design has significantly increased the potential and versatility of the upper back flaps in reconstruction of severe neck scar contracture.

Hemodynamic Assessment with SPY-Indocyanine Green Angiography in Expansion Period: A Study for Expansion Capsule Pressure Optimization.

Tissue expansion-related severe complication exists, and the poor blood supply is one of the causes. After decades of negative correlation between capsule pressure and blood flow was verified, the widely recognized expansion capsule pressure is still absent. A prospective randomized controlled trial was performed to explore the optimal expanding capsule pressure. Thirty subjects were randomly divided into 5 groups, received a weekly expanding on 60-, 70-, 80-, 90-, and 100-mm Hg capsule pressure, respectively. All patients achieved 8-week follow-up; hemodynamic assessment by SPY-indocyanine green (ICG) angiography was taken every 2 weeks. Standardized indexes from SPY-ICG angiography were used to assess the blood supply, in which the ratio of ingress rate and the ingress rate of normal skin (IR/NIR) reflects the arterial perfusion level, and the ratio of Engress Rate and IR (ER/IR) indicates the venous reflux level. The expansion-related adverse events during the trial were recorded. The IR/NIR and the ER/IR are both obviously negatively correlated to the capsule pressure of tissue expander (P ≤ 0.05, the ER/IR's correlation coefficient = -0.453; the IR/NIR's correlation coefficient = -0.482). The post-expansion IR/NIR increased significantly after 8 weeks of expansion (P ≤ 0.05) in 90-mm Hg group. And the post-expansion ER/IR was significantly elevated (P ≤ 0.05) in 80 and 90-mmHg groups. There were 2 expansion-related complications reported in 100-mm Hg group, whereas no complication occurred in 4 other lower groups. SPY-ICG angiography is an objective measurement for tissue expansion hemodynamic monitoring. The expanding capsule pressure of 80 to 90 mm Hg is a reasonable upper limit.

Postburn Neck Contracture: Principles of Reconstruction and a Treatment Algorithm.

BACKGROUND: Various techniques have been developed for postburn neck reconstruction, but a treatment algorithm is needed. METHODS: We retrospectively reviewed all patients treated for postburn neck contracture at our institution between February 2008 and December 2015. Necks were divided into one anterior subunit and two lateral subunits marked by the sternocleidomastoid muscle. Deformities were categorized into three types according to their size and location. Type I deformities involve less than one subunit, type II deformities involve at least one subunit but less than two subunits, and type III deformities affect two or more subunits. Type II deformities were further divided into type IIa deformities, which mainly involve the anterior region, and type IIb deformities, which mainly involve the lateral region. RESULTS: Local random pattern flaps were constructed for type I deformities. Pedicled flaps from the anterior chest and supraclavicular areas were preferred for type IIa deformities, and pedicled flaps from the back were preferred for type IIb deformities. Pedicled flaps from other areas were the second choice for type II deformities, followed by free and prefabricated flaps. For type III deformities, bipedicled flaps were usually required. At a follow-up of at least 12 months, all patients showed near-normal neck function, and aesthetic features were significantly improved. CONCLUSION: The proposed classification and treatment algorithm for postburn neck reconstruction may help achieve satisfactory outcomes.

Preoperative Imaging for Thoracic Branch of Supraclavicular Artery Flap: A Comparative Study of Contrast-Enhanced Ultrasound With Three-Dimensional Reconstruction and Color Duplex Ultrasound.

OBJECTIVE: The thoracic branch of supraclavicular artery (TBSA) flap has been widely used to reconstruct face and neck defects. However, the branches of the supraclavicular artery (SCA) exhibit considerable anatomical variations. The aim of this study was to evaluate and compare the role of contrast-enhanced ultrasound (CEUS) with 3-dimensional (3D) reconstruction and regular color duplex ultrasonography (CDUS) in the preoperative assessment of TBSA flap. METHODS: From May 2009 to October 2013, 20 patients (involving 26 flaps) receiving anterior chest flaps for lower face and neck reconstruction underwent both CDUS and CEUS with 3D reconstruction preoperatively for detecting the TBSAs. The number of TBSAs, their caliber, peak systolic velocity (PSV), and course were recorded. In case of an absent TBSA, the second and third perforators of the internal mammary artery were detected. The preoperative imaging data were compared with the intraoperative findings to evaluate the value of CDUS and CEUS with 3D reconstruction for planning and performing the TBSA flaps. All patients were followed up for more than 1 year. RESULTS: A total of 37 TBSAs in 16 flaps were found by CDUS with a mean caliber of 0.6 ± 0.1 mm and a mean PSV of 13.1 ± 1.6 cm/s, whereas 48 TBSAs in 20 flaps were found by CEUS with a mean caliber of 0.8 ± 0.2 mm and a mean PSV of 12.5 ± 2.1 cm/sec. In 18 flaps with TBSA PSV above 10 cm/s, pedicled TBSA flaps were performed, whereas pedicled or free internal mammary artery flaps were chosen as alternative for the remaining 8 flaps. All 48 TBSAs were found intraoperatively and their origin from the SCA confirmed, indicating specificity and positive predictive value of both CDUS and CEUS were 100% in localizing TBSA preoperatively, whereas sensitivity and negative predictive value of CEUS were higher than using CDUS. CONCLUSIONS: The branches of SCA have marked anatomical variations. CEUS with 3D reconstruction has advantages over CDUS for the preoperative assessment of the donor-site vascular supply of TBSA flaps.

Autologous Tissue Repair and Total Face Restoration.

Importance: Total face restoration remains a challenge in modern reconstructive surgery. After 17 years of experiments and preliminary clinical studies, a new concept of face prefabrication was developed for face restoration with autologous tissue. Objective: To evaluate the long-term results of face restoration with autologous tissue and report a finalized and standardized approach of face prefabrication. Design, Setting, and Participants: In this single-center long-term retrospective study, 32 patients who underwent total face restoration between 2005 and 2022 were reviewed. These patients underwent total facial reconstruction, which included flap prefabrication, 3-dimensional printing, tissue expansion, and flap transfer with aid of indocyanine green angiography (IGA). The flap first undergoes prefabrication by transferring vascularized fascia under the skin of the selected chest. A tissue expander is then placed under the fascia to create a large, thin, reliable skin flap after expansion. Once completed, the flap is transferred to the face during the second stage of the reconstruction. Intraoperative IGA is performed to guide the design of subsequent openings for facial fissures. Data were analyzed from July to September 2023. Main Outcomes and Measures: Flap healing, reconstructive outcome, and patient recovery were assessed during follow-up. Three questionnaires, including the 36-Item Short Form Health Survey (SF-36), Aesthetic and Functional Status Score of Facial Soft-Tissue Deformities/Defects, and the EuroQoL Health-Related Quality of Life (EQ-5D-5L), were used to evaluate the quality of life and satisfaction with facial aesthetic and functional status. Results: Of 24 included patients, 14 (58%) were male, and the mean (range) age was 32.9 (8-62) years. The mean (range) follow-up was 5.6 (2-12) years. All patients reported a significant improvement in quality of life (SF-36), especially in mean (SD) social functioning (preoperative score, 53.65 [34.51]; postoperative score, 80.73 [19.10]) and emotional stability (preoperative score, 56.67 [25.55]; postoperative score, 71.17 [18.51]). A total of 22 patients (92%) went back to work. Mean (SD) facial aesthetic status (preoperative score, 4.96 [3.26]; postoperative score, 11.52 [3.49]; P < .001) and functional status (preoperative score, 11.09 [3.51]; postoperative score, 15.78 [3.26]; P < .001) also improved. In addition, there was a significant increase in overall satisfaction and self-reported health status (preoperative score, 8.13 [1.52]; postoperative score, 3.58 [2.31]). Conclusions and Relevance: In this study, 5-year follow-up results suggested that this innovative approach to total face restoration offered a safe and valid option for indicated patients, with acceptable reconstructive and cosmetic outcomes.

Midface Prelamination by using a Three-dimensional Cervicothoracic Prefabricated Flap.

SUMMARY: The midface is an important area in aesthetics and function and a complex area to manage after burn injuries, trauma, and tumor resection. Traditional treatment to reconstruct midface defects involving the nose, lips and cheeks requires multiple sequential flap surgeries but results in a patch-like appearance, which remains a major challenge for head and neck reconstructive surgeons. This article describes how the authors perform prelamination using the prefabricated cervicothoracic flap on the anterior chest for midface reconstruction. The key point of the authors' procedure is to three-dimensionalize the cervicothoracic prefabricated flap with flap folding, flap rotation, and cartilage grafts for coverage, lining, and support of the nose and lips. This technique may be indicated for extensive midface defects involving total nose and lip loss. It provides a uniform matched facial appearance and significant functional improvement. Donor-site morbidity and the need for multiple flap procedures could be reduced.

Intraoperative Indocyanine Green Angiography Facilitates Flap Fenestration and Facial Organ Fabrication in Total Facial Restoration.

BACKGROUND: As effective measures to visualize flap vasculature and perfusion were unavailable, flap fenestration and facial organ fabrication could not be performed safely, preventing the transition from 2-D coverage to the restoration of the 3-D structure of facial organs. This study aims to evaluate the efficacy of indocyanine green angiography (ICGA) in guiding flap fenestration and facial organ fabrication in total facial restoration. METHODS: Ten patients with total facial scarring following burn injury were enrolled in the study. They were treated with pre-expanded, prefabricated monoblock flaps for total face restoration. The opening of nostrils, oral and palpebral orifices, together with organ fabrication, were conducted under the guidance of intraoperative ICGA via hemodynamic evaluation of flap perfusion. Postoperative follow-up parameters include vascular crisis, infection, flap necrosis and patients' aesthetic and functional recovery. RESULTS: The opening of facial organ orifices was performed at the stage of flap transfer in nine patients. To avoid damaging the major nourishing vessels, the left palpebral orifice was opened eight days after the flap transfer in one patient, as observed by ICGA. Based on ICGA evaluation, the decision to perform additional vascular anastomosis before flap fenestration was made in six patients. Hemodynamic analysis of flap perfusion following fenestration revealed no significant change. Follow-up showed satisfactory aesthetic recovery and well-restored 3-D structures of facial organs. CONCLUSION: This pilot study demonstrates how intraoperative ICGA can enhance the safety of flap fenestration, thereby transforming full facial restoration from the 2-D to the 3-D realm by facilitating facial organ fabrication.

CD39+ Fibroblasts Enhance Myofibroblast Activation by Promoting IL-11 Secretion in Hypertrophic Scars.

Fibroblasts (Fbs) are critical to hypertrophic scar (HTS) formation and were recently shown to be highly heterogeneous. However, Fb heterogeneity in HTSs has not been fully elucidated. In this study, we observed an increased fraction of CD39+ Fbs in HTS after screening four Fb subtypes (CD26+, CD36+, FAP+, and CD39+). CD39+ Fbs, enriched in the upper dermis, were positively correlated with scar severity. The transcriptional analysis of CD39+ and CD39- Fbs sorted from HTS revealed that IL-11 was more highly expressed in CD39+ Fbs. We then showed that IL-11 was upregulated in HTSs and that its expression was induced by TGFß1 in vitro. TGFß1 also stimulated the expression of CD39 at the transcriptional and protein levels, mediating the maintenance of the CD39+ phenotype. Furthermore, IL-11 facilitated myofibroblast activation and extracellular matrix production in both CD39+ and CD39- Fbs. Interestingly, CD39+ Fbs secreted more IL-11 on TGFß1 treatment and were less responsive to IL-11 than CD39- Fbs. Notably, a CD39 inhibitor effectively reduced stretch-induced scar formation and attenuated bleomycin-induced skin fibrosis, suggesting an antiscarring approach by targeting CD39+ Fbs.

Single-Cell Transcriptomics Uncover Key Regulators of Skin Regeneration in Human Long-Term Mechanical Stretch-Mediated Expansion Therapy.

Tissue expansion is a commonly performed therapy to grow extra skin in vivo for reconstruction. While mechanical stretch-induced epidermal changes have been extensively studied in rodents and cell culture, little is known about the mechanobiology of the human epidermis in vivo. Here, we employed single-cell RNA sequencing to interrogate the changes in the human epidermis during long-term tissue expansion therapy in clinical settings. We also verified the main findings at the protein level by immunofluorescence analysis of independent clinical samples. Our data show that the expanding human skin epidermis maintained a cellular composition and lineage trajectory that are similar to its non-expanding neighbor, suggesting the cellular heterogeneity of long-term expanded samples differs from the early response to the expansion. Also, a decrease in proliferative cells due to the decayed regenerative competency was detected. On the other hand, profound transcriptional changes are detected for epidermal stem cells in the expanding skin versus their non-expanding peers. These include significantly enriched signatures of C-FOS, EMT, and mTOR pathways and upregulation of AREG and SERPINB2 genes. CellChat associated ligand-receptor pairs and signaling pathways were revealed. Together, our data present a single-cell atlas of human epidermal changes in long-term tissue expansion therapy, suggesting that transcriptional change in epidermal stem cells is the major mechanism underlying long-term human skin expansion therapy. We also identified novel therapeutic targets to promote human skin expansion efficiency in the future.

Augmentation of Perforator Flap Blood Supply with Vascular Supercharge or Flap Prefabrication: Evaluation in a Rat Model.

BACKGROUND: Vascular supercharge and flap prefabrication are two surgical maneuvers to improve flap blood supply. Although these techniques have been studied intensively, few studies have focused on the differences between supercharge and prefabricated flaps regarding their flap survival areas, vasculatures, and hemodynamics. METHODS: In this study, 21 male Sprague-Dawley rats were divided into three groups as follows: group A, single perforator flap; group B, supercharge flap; and group C, prefabricated flap. Flap survival was measured 1 week after flap elevation. Indocyanine green angiography was applied to visualize flap vascularity and to analyze flap hemodynamics. Von Willebrand factor immunohistochemical staining was applied to assess the number of microvessels in the choke zone of the abdominal wall. RESULTS: The flap survival areas were expanded significantly in the arteriovenous supercharge group and the vascular bundle prefabricated group compared with that in the single-perforator group (81.34 ± 8.12 percent and 75.51 ± 8.08 percent versus 46.27 ± 10.01 percent, respectively; p < 0.05). Hemodynamic analysis suggested that although a significant increase in arterial infusion could be achieved with flap prefabrication, the venous effusion of the prefabricated flap was the worst among the three groups, indicating greater susceptibility to compromised venous return. Active neovascularization was confirmed by an increased number of microvessels in group C. Specifically, the dilatation of choke vessels and the newly formed vessels of the prefabricated pedicle could be appreciated by indocyanine green angiographic mapping. CONCLUSIONS: Both vascular supercharge and flap prefabrication can augment the blood supply of the perforator flap but by means of different mechanisms. Because a supercharge flap is less susceptible to venous compromise, it is suggested to first consider the use of vascular supercharging when feasible.

The role of macrophages in the formation of hypertrophic scars and keloids.

Numerous studies have shown that macrophages can orchestrate the microenvironment from the early stage of wound healing to the later stages of scar formation. However, few reviews have highlighted the significance of macrophages during the formation of abnormal scars. The purpose of this review was to outline the polarization of macrophages from early to late stage of pathological scar formation, focusing on spatiotemporal diversity of M1 and M2 macrophages. In this review, the role of macrophages in the formation of hypertrophic scars and keloids is summarized in detail. First, an increased number of M2 cells observed before injuries are significantly associated with susceptibility to abnormal scar pathogenesis. Second, decreased expression of M1 at the early stage and delayed expression of M2 at the late stage results in pathological scar formation. Third, M2 cells are highly expressed at both the margin and the superficial region, which is consistent with the invasive property of keloids. Finally, this review helps to characterize strategies for the prediction and prevention of pathological scar formation.

Investigating the potential of LSKL peptide as a novel hypertrophic scar treatment.

Hypertrophic scar (HTS) is a common pathologic dermal fibroproliferative disease after skin injury. Transforming growth factor ß (TGF-ß) plays a central role in HTS formation and development. Thrombospondin-1 (TSP-1) activates latent TGF-ß by binding to latency-associated peptide-ß on TGF-ß structure. So far, LSKL peptide was shown to selectively antagonize TSP-1. In this study, TSP-1 was first confirmed to be highly expressed in HTS. LSKL peptide was proven to inhibit the overexpression of extracellular matrix and contractile ability of HTS fibroblasts. In vivo, LSKL could attenuate the thickness of HTS, distortion of collagen alignment and fibrogenesis. Results also demonstrated that LSKL peptide not only remarkably attenuated cell proliferation and migration, but also induced cell apoptosis of HTS fibroblasts. Western blot analysis further revealed that LSKL peptide significantly suppressed the phosphorylation of PI3K, AKT, and mTOR, while not affecting the phosphorylation of Smad2/3 and MEK/ERK. These findings suggested that LSKL might be a promising anti-fibrosis agent to HTS through PI3K/AKT/mTOR signaling pathway.

Augmentation of Perforator Flap Blood Supply with Sole or Combined Vascular Supercharge and Flap Prefabrication for Difficult Head and Neck Reconstruction.

Importance: The strategic option between vascular supercharge and flap prefabrication in the fabrication of multipedicle flaps for difficult head and neck reconstruction has not been reported. Objectives: To summarize our 13-year experience in the design of multipedicle pre-expanded perforator flaps for extensive head and neck defect reconstruction, with vascular supercharge and flap prefabrication, either solely or in combination. To discuss the strategy for judicious selection between these techniques in the design of multipedicle flaps at different donor sites. Design, Setting, and Participants: A retrospective study was performed in patients with severe head and neck deformities and treated with multipedicle pre-expanded perforator flaps between May 2005 and May 2018. Intraoperative indocyanine green angiography was utilized for visualization of flap perfusion and analysis of the hemodynamics of pre-existing perforator and prefabricated vessels. Main Outcomes and Measures: The main outcomes measured were (1) features of deformities, (2) multipedicle flap designs, and (3) postoperative complications and long-term functional and aesthetic outcomes. Results: Seventy-five multipedicle pre-expanded perforator flaps were harvested, including 44 supercharged, 26 prefabricated, and 5 tripedicle, combining both techniques, with sizes ranging from 22 × 12 to 45 × 27 cm2. Hemodynamic analysis demonstrated slower arterial inflow (0.60 ± 0.29 U/s vs. 2.65 ± 1.29 U/s, p < 0.05) and venous outflow (0.10 U/s vs. 0.23 ± 0.11 U/s) in prefabricated vessels, compared to the pre-existing perforator, namely the internal mammary arterial perforator. Partial necroses were observed in three patients with only one requiring skin grafting. The aesthetic and functional outcomes were satisfying after reconstruction. Conclusions and Relevance: Multipedicle pre-expanded perforator flaps fabricated by vascular supercharge and flap prefabrication, either solely or in combination in various donor sites, are powerful reconstructive tools for extensive head and neck defects. For a more reliable design, vascular supercharging should be considered a priority strategy, and flap prefabrication an alternative when suitable supercharging vessels are unavailable.

A case of scalp avulsion with prolonged ischemic time: indocyanine green angiography can aid in predicting replant survival.

BACKGROUND: Microsurgical replantation has become the most favorable treatment option for scalp avulsion. However, the accurate prediction of postoperative replant viability remains challenging. CASE PRESENTATION: In this article, we showed that (indocyanine green angiography, ICGA) can provide a much more precise prediction of replant necrosis than conventional clinical assessment in a rare case of complete scalp avulsion with prolonged ischemia time. CONCLUSION: Clinical assessment of replant survival may be misleading in cases of complex tissue injuries and prolonged ischemic stress. This case provides insight into the promising utility of ICGA as an important adjuvant tool to better assess tissue perfusion and viability in scalp avulsion and possibly other types of replantation.