Hirudin enhances perforator flap survival: Clinical application report and mechanistic exploration.

BACKGROUND AND PURPOSE: Hirudin, a potent anticoagulant, is used in traditional Chinese medicine (TCM) to treat thrombotic conditions and prevent postoperative thrombosis. Coagulation-related vascular complications are a common cause of perforator flaps failure. This study explores hirudin's potential to enhance flap growth by mitigating coagulation-related issues. MATERIALS AND METHODS: Patients were divided into GroupⅠ(hirudin group) and GroupⅡ(control). Laboratory tests covered red blood cell count (RBC), hematocrit (HCT), platelet count (PLT), monocyte count (MONO), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), and D-Dimer. Clinical parameters, including capillary refill time (CRT), flap swelling, and survival status, were evaluated. Animal experiments used Sprague-Dawley (SD) rats to establish random skin flaps. The experimental side received hirudin injection, while the control side received saline. Flaps were photographed to calculate survival rate, and CD31 immunohistochemical (IHC) analysis was performed to calculate microvessel density (MVD). RESULTS: The study, with 29 patients, found significant CRT differences between groups on postoperative days 2 and 6 (p = 0.027; p = 0.019), favoring GroupⅠ. Swelling severity varied significantly over time; GroupⅡhad more pronounced swelling. GroupⅠshowed superior flap growth with fewer complications, statistically significant (p = 0.033). Specific lab indicators (MONO, PT, and FIB) were significant at certain times. In animal experiments, the experimental side consistently had higher flap survival and slightly increased CD31 expression at various times, with higher MVD on days 2 and 6. CONCLUSIONS: Hirudin enhances flap survival through diverse mechanisms, supporting its role as a complementary approach in perforator flap surgeries.

[Clinical diagnosis and treatment of 14 cases of scar cancer ulcer wound on head and face].

Objective: To analyze the clinical characteristics of scar cancer ulcer wound of head and face, and to investigate its diagnosis and treatment. Methods: The clinical data of 14 patients with head and facial scar cancer ulcer wounds who met the selection criteria and admitted between January 2021 and March 2022 were retrospectively analyzed. There were 8 males and 6 females. The age of onset ranged from 21 to 81 years with an average age of 61.6 years. The incubation period ranged from 1 month to 70 years, with a median of 4 years. Site of the disease included 7 cases of head, 6 cases of maxillofacial region, and 1 case of neck region. Injury factors included trauma in 5 cases, scratch in 5 cases, scalding in 2 cases, burn in 1 case, and needle puncture in 1 case. Pathological results showed squamous cell carcinoma in 9 cases, basal cell carcinoma in 3 cases, sebaceous adenocarcinoma in 1 case, papillary sweat duct cystadenoma combined with tubular apocrine sweat gland adenoma in 1 case. There was 1 case of simple extensive tumor resection, 1 case of extensive tumor resection and skin grafting repair, 7 cases of extensive tumor resection and local flap repair, and 5 cases of extensive tumor resection and free flap repair. Results: All the 14 patients were followed up 16-33 months (mean, 27.8 months). Two patients (14.29%) had scar cancer ulcer wound recurrence, of which 1 patient recurred at 2 years after 2 courses of postoperative chemotherapy, and was still alive after oral traditional Chinese medicine treatment. One patient relapsed at 1 year after operation and died after 2 courses of chemotherapy. One patient underwent extensive resection of the left eye and periocular tumor and the transfer and repair of the chimaeric muscle axial flap with the perforating branch of the descending branch of the left lateral circumflex femoral artery, but the incision healing was poor after operation, and healed well after anti-infection and debridement suture. The wounds of other patients with scar cancer ulcer did not recur, and the wounds healed well. Conclusion: Scar cancer ulcer wound of the head and face is common in the middle-aged and elderly male, and the main pathological type is squamous cell carcinoma. Local extensive resection, skin grafting, or flap transfer repair are the main treatment methods. Early active treatment of wounds after various injuries to avoid scar repeated rupture and infection is the foundamental prevention of scar cancer.

Dihydrocapsaicin suppresses the STING-mediated accumulation of ROS and NLRP3 inflammasome and alleviates apoptosis after ischemia-reperfusion injury of perforator skin flap.

Avascular necrosis frequently occurs as a complication following surgery involving the distal perforator flap. Dihydrocapsaicin (DHC) can protect tissue from ischemia-reperfusion (I/R) injury, but its specific role in multizone perforator flaps remains unclear. In this study, the prospective target of DHC in the context of I/R injury was predicted using network pharmacology analysis. Flap viability was determined through survival area analysis, laser Doppler blood flow, angiograms, and histological examination. The expressions of angiogenesis, apoptosis, NLR family pyrin domain containing 3 (NLRP3) inflammasome, oxidative stress, and molecules related to cyclic guanosine monophosphate (GMP)-adenosine monophosphate synthase (cGAS)-interferon gene stimulant (STING) pathway were assessed using western blotting, immunofluorescence, TUNEL staining, and dihydroethidium (DHE) staining. Our finding revealed that DHC promoted the perforator flap survival, which involves the cGAS-STING pathway, oxidative stress, NLRP3 inflammasome, apoptosis, and angiogenesis. DHC induced oxidative stress resistance and suppressed the NLRP3 inflammasome, preventing apoptosis in vascular endothelial cells. Through regulation of STING pathway, DHC controlled oxidative stress in endothelial cells and NLRP3 levels in ischemic flaps. However, activation of the cGAS-STING pathway led to the accumulation of reactive oxygen species (ROS) and NLRP3 inflammasome, thereby diminishing the protective role of DHC. DHC enhanced the survival of multidomain perforator flaps by suppressing the cGAS-STING pathway, oxidative stress, and the formation of NLRP3 inflammasome. These findings unveil a potentially novel mechanism with clinical significance for promoting the survival of multidomain perforator flaps.

The Application of Preoperative Computed Tomography Angiography and Color Ultrasound Assisted Lower Limb Perforator Flap Design in the Repair of Lower Limb Soft Tissue Defects.

Objective: The goal of this study was to explore the application effect of preoperative computed tomography (CT) angiography and color ultrasound-assisted design of lower limb perforator flaps in the repair of lower limb soft tissue defects. Repair of soft tissue defects in the lower limbs is a challenging surgical task, and accurate preoperative location of vascular structures and detailed design of the surgical plan are crucial to the success of the surgery. This study aims to improve the accuracy and effectiveness of lower limb perforator flap repair surgery by introducing CT angiography and color ultrasound technology. Methods: Sixty-four patients who underwent lower limb soft tissue defect repair with perforator flaps were enrolled at our hospital from February 2020 to February 2023. According to their admission time, they were divided into two groups: 32 patients admitted before June 31, 2022, were included in the control group, and preoperative color Doppler ultrasound was used to assist in designing the lower limb perforator flap; 32 patients admitted after June 31, 2022, were included in the study group, and preoperative CT angiography and color Doppler ultrasound were used to assist in designing the lower limb perforator flap. Specifically, we conducted detailed records and analyzes of patients' age distribution, gender ratio, and relevant medical history. This demographic information will help reveal whether there are differences in the effectiveness of preoperative CT angiography and color ultrasound-assisted lower extremity perforator flap design among different patient groups. By considering these key factors, we can more accurately assess the actual utility of new technologies in different patient groups and provide more specific guidance for clinical practice.The therapeutic effects of the two groups of patients were recorded. The differences between the preoperative CT angiography measurements and intraoperative actual measurements of the study group were compared. Clinical indicators, sensory function in the graft area, flap survival rate, flap complication rate, and donor area complication rate were compared between the two groups. The satisfaction of patients in the two groups with the recovery of the surgical area was also compared. Results: The treatment success rate of the study group was higher than that of the control group (P < .05). There was no significant difference in the preoperative CT angiography measurements (shallow branch localization, shallow branch starting diameter, shallow branch length, deep branch starting diameter) and intraoperative actual measurements of the study group (P > .05). The operation time and intraoperative blood loss of the study group were shorter than those of the control group (P < .05), and there was no significant difference in flap harvesting area and length of hospital stay between the two groups (P > .05). There was a difference in sensory function in the graft area between the two groups, with a higher proportion of S4 grade in the study group and better recovery compared to the control group (P < .05). There was no significant difference in satisfaction evaluation between the two groups (P > .05). Conclusion: Preoperative CT angiography and color ultrasound-assisted design of lower limb perforator flaps have shown significant clinical advantages in repairing lower limb soft tissue defects, improving treatment effects and surgical efficiency. In clinical practice, this technology is expected to reduce surgical complexity, shorten surgical time, reduce the risk of intraoperative bleeding, and achieve effective defect repair while maintaining or improving the patient's sensory function.However, there are some limitations to the study, such as the relatively small sample size and single-center nature. Future research can optimize the operation process of this technology, expand the scope of research, and explore its application in the repair of soft tissue defects caused by specific causes. This technology may provide more precise and effective options for personalized treatment, especially for patients who need to preserve more sensory function.

[Curative effects of bi-pedicled deep inferior epigastric perforator flap in repairing large soft tissue defects in the lower limbs].

Objective: To investigate the curative effects of bi-pedicled deep inferior epigastric perforator (DIEP) flap in repairing large soft tissue defects in the lower limbs. Methods: A retrospective observational study was conducted. From February 2016 to June 2020, 16 patients with large soft tissue defects in the lower limbs caused by trauma or after tumor/scar resection were admitted to the Department of Hand Surgery of the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, including 9 males and 7 females, aged 25-58 years, with the area of soft tissue defects ranging from 14.0 cm×8.0 cm to 32.0 cm×18.0 cm. Using the abdomen as the donor site, the conjoined abdominal wall flap, i.e., the bi-pedicled DIEP flap (with an area ranging from 15.0 cm×9.0 cm to 32.0 cm×20.0 cm) carrying two sets of the trunk of the deep inferior epigastric artery was designed and resected to repair the wound. The donor site wound was sutured directly. The flap survival and wound healing in the donor and recipient areas were observed after operation. The curative effect was evaluated during the follow-up. At the last follow-up, the American Knee Society score and lower extremity functional scale were used to assess the functions of knee joint and lower limb, respectively. Results: The flaps of 15 patients survived after operation; the flap of one patient had partial infection at the edge after operation but healed after debridement and dressing change. The wounds in the donor and recipient areas of 16 patients all healed well. Follow-up of 16-28 months showed that the recipient area had a good shape and pliable texture, and there was no obvious swollen appearance, hyperpigmentation, or abnormal hair growth; the donor site had linear scar only, with no complications such as abdominal hernia or hyperplastic scar; the functions of knee joint and lower limb were well reconstructed, with no recurrence of tumor. At the last follow-up, among the 4 patients with knee joint injury, 3 cases were excellent and 1 case was good in the evaluation of knee joint function; among the 12 patients with lower limb injury, 9 cases were excellent and 3 cases were good in the evaluation of lower limb function. Conclusions: The donor site of bi-pedicled DIEP flap is concealed with abundant tissue and large area for resection, with which can be used to repair large soft tissue defects in the lower limbs, achieving good short-term results of appearance and function restoration.

Preservation of deep epigastric perforators during anterior component separation technique (ACST) results in equivalent wound complications compared to transversus abdominis release (TAR).

PURPOSE: The use of component separation results in myofascial release and increased rates of fascial closure in abdominal wall reconstruction(AWR). These complex dissections have been associated with increased rates of wound complications with anterior component separation having the greatest wound morbidity. The aim of this paper was to compare the wound complication rate between perforator sparing anterior component separation(PS-ACST) and transversus abdominus release(TAR). METHODS: Patients were identified from a prospective, single institution hernia center database who underwent PS-ACST and TAR from 2015 to 2021. The primary outcome was wound complication rate. Standard statistical methods were used, univariate analysis and multivariable logistic regression were performed. RESULTS: A total of 172 patients met criteria, 39 had PS-ACST and 133 had TAR performed. The PS-ACST and TAR groups were similar in terms of diabetes (15.4% vs 28.6%, p = 0.097), but the PS-ACST group had a greater percentage of smokers (46.2% vs 14.3%, p < 0.001). The PS-ACST group had a larger hernia defect size (375.2 ± 156.7 vs 234.4 ± 126.9cm2, p < 0.001) and more patients who underwent preoperative Botulinum toxin A (BTA) injections (43.6% vs 6.0%, p < 0.001). The overall wound complication rate was not significantly different (23.1% vs 36.1%, p = 0.129) nor was the mesh infection rate (0% vs 1.6%, p = 0.438). Using logistic regression, none of the factors that were significantly different in the univariate analysis were associated with wound complication rate (all p > 0.05). CONCLUSION: PS-ACST and TAR are comparable in terms of wound complication rates. PS-ACST can be used for large hernia defects and promote fascial closure with low overall wound morbidity and perioperative complications.

Treatment of Advanced Male Genital Lymphedema With a Complete Functional Lymphatic System Pedicled Transfer.

OBJECTIVE: To evaluate the functional efficacy of the superficial circumflex iliac artery perforator (SCIP) -lymphatic pedicled flap in the treatment of advanced male genital lymphedema. METHODS: From February 2018 to January 2022, we treated 26 male patients with scrotal and penoscrotal advanced lymphedema using reconstructive lymphatic surgery. Isolated scrotal involvement was seen in 15 patients, and 11 patients had penoscrotal involvement. Excision of genital lymphedematous fibrotic tissue was followed by reconstruction utilizing the SCIP-lymphatic flap. Patient characteristics, intraoperative data, and postoperative results were evaluated. RESULTS: The mean patient age was 39 ± 4.6, and the mean follow-up time was 44.9 months. the SCIP-lymphatic flap was used to reconstruct partial (n = 11) or total (n = 15) scrotum and used to reconstruct total penile skin in 9 cases and partial in 2 cases. The flap survival rate was 100%. Cellulitis rates were dramatically reduced after reconstruction (P value <.001). The mean genital lymphedema score (GLS) after surgery was 0.05, which was significantly lower than the preoperative 1, 6.2 (P < .001). The median Glasgow Benefit Inventory (GBI) total score was +41, all 26 patients (100%) showed a degree of quality of life improvement. CONCLUSION: The pedicled SCIP lymphatic transfer approach in advanced male genital lymphedema can provide a durable complete functional lymphatic system that improves the appearance and genital lymphatic drainage. This leads to an improvement in quality of life as well as in sexual functions.

Effects of Preconditioning With Transcutaneous Electrical Nerve Stimulation Monitored by Infrared Thermography on the Survival of Pedicled Perforator Flaps in a Rat Model.

OBJECTIVE: Pedicled perforator partial or complete necrosis with a rate of 13.7%. This study was undertaken to test whether preconditioning with transcutaneous electrical nerve stimulation (TENS) monitored by infrared thermography protect against partial necrosis by converting the choke anastomoses to the true anastomoses via inducing heme oxygenase-1 (HO-1) in a rat pedicled perforator flap model. METHODS: Seventy-two Sprague-Dawley rats were randomly assigned to the control, the TENS, the TENS + SnPP (tin protoporphyrin; HO-1 activity inhibitor; 50 µmol/kg) and the TENS +0.9% saline groups. On the unilateral dorsum of the rats, a rectangular flap donor site of 11 × 3 cm was marked out, which contained three perforator angiosomes and two choke zones. On days 1, 3 and 4, 1 hour of TENS (biphasic pulses, 25 mA, 80 Hz, 200 µs) was applied to the flap donor sites, respectively. On day 5, after the flap donor sites were assessed by infrared thermography, the flaps were harvested based on the deep circumflex iliac artery perforator. RESULTS: Infrared thermography showed that the choke zones in the flap donor sites presented white in the TENS and the TENS +0.9% saline groups, whereas they presented red in the control and the TENS + SnPP groups. Postmortem arteriography showed that the number of arterioles across each choke zone significantly increased in the TENS and the TENS +0.9% saline groups compared with the control and the TENS + SnPP groups. Immunohistochemistry and western blot showed a significant increase in HO-1 in the choke zones after TENS preconditioning. The necrotic area percentage of the flaps was significantly decreased in the TENS (4.3% ± 2.6%) and the TENS +0.9% saline groups (4.5% ± 2.3%) compared with the control (24.8% ± 5.0%) ( P < 0.001); there was no significant difference between the TENS and the TENS + SnPP (24.4% ± 7.3%) groups. CONCLUSIONS: These data show that TENS preconditioning monitored by infrared thermography might be a promising strategy to prevent pedicled perforator flaps from partial necrosis.

Superior gluteal artery perforator flap salvaged via hyperbaric oxygen therapy.

The superior gluteal artery perforator (SGAP) flap can be challenging and in common with all flaps can develop venous and arterial insufficiency. Several prior studies have demonstrated the successful utility of hyperbaric oxygen therapy (HBOT) in the salvage of compromised flaps, mainly with deep inferior epigastric perforator, latissimus dorsi or transverse rectus abdominis myocutaneous flaps. SGAP flaps are autologous alternatives to abdominal-based flaps and provides adequate adipose tissue for breast reconstruction. We report a case of a woman in her 50s who underwent a delayed bilateral breast reconstruction using SGAP free flaps. Postoperatively, venous congestion of her right breast flap was noted for which she was referred for HBOT. An acceptable aesthetic result was achieved following 17 HBOT treatments. This is the first case we can find in the published literature of ischaemic SGAP free flap being salvaged by HBOT.

Retrograde Manual Lymphatic Drainage following Vascularized Lymph Node Transfer to Distal Recipient Sites for Extremity Lymphedema: A Retrospective Study and Literature Review.

BACKGROUND: Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites. METHODS: Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared. RESULTS: One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group. CONCLUSION: Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Mycobacterium mageritense infection following mastectomy and breast reconstruction requiring triple antibiotic therapy and surgical debridement.

A 40-year-old woman was referred to infectious disease specialists for a Mycobacterium mageritense skin infection following mastectomy and bilateral reconstruction with deep inferior epigastric perforator flap. Her case demonstrates the difficulty in treating non-tuberculosis mycobacterial infections, especially the rarely seen species. She failed to respond to dual antibiotic therapy containing imipenem-cilastin despite reported sensitivity. Additionally, her course was complicated by intolerance to various regimens, including gastrointestinal distress, a drug rash with eosinophilia and systemic symptoms, and tendinopathy. With few published data, no treatment guidelines, and limited medications from which to choose for M. mageritense, her treatment posed a challenge. She ultimately required aggressive surgical intervention and a triple therapy antibiotic regimen. The duration of our patient's treatment and the extent of her complications suggest a potential need for early surgical intervention in postsurgical wounds infected with M. mageritense that do not respond to conventional treatment.

The Effect of Botulinum Toxin on Flap Viability of the Posterior Thigh Perforator Flap in Rats.

BACKGROUND: The use of perforator propeller flaps in lower limb reconstruction has increased recently. Many pharmacological agents are used to increase flap viability. Botulinum toxin has been used in various types of flaps in the literature. However, there is no study regarding the use of botulinum toxin in the lower limb propeller flaps. This study investigates the effect of botulinum toxin administration on flap survival for lower limb propeller flap in rats. MATERIALS AND METHODS: The study included 20 male Wistar albino rats, divided into two groups with a flap rotation of 90° in group 1 and 180° in group 2. In both groups, botulinum toxin was administered to the right thigh and a physiological saline solution was applied to the left thigh. Five days later, flaps were elevated over the posterior aspect of the right and left thighs and inset after 90° and 180° rotation was performed. Histopathological, immunohistochemical, and necrosis area analyses were performed. RESULTS: Necrosis area, edema, polymorphonuclear leukocyte infiltration, and necrosis were found to be higher on the left side of the groups, whereas epidermal thickness, collagen density, vascularization, and hair root density were found to be higher on the right side of the groups. No significant difference was found between the right posterior thighs in either group on any parameter other than vascularization. Histopathologically and immunochemically statistically significant differences were found between the two groups. CONCLUSIONS: The present study found that botulinum toxin increases flap viability in lower limb perforator-based propeller flaps.

The Effect of Leonurine on Multiterritory Perforator Flap Survival in Rats.

BACKGROUND: Leonurine (Leo), a natural active compound of Leonurus cardiaca, has been shown to possess various biological activities. However, it is not known whether Leo promotes perforator flap survival. METHODS: In this study, a perforator flap was outlined in the rat dorsum. The rats that survived surgery were divided randomly to control and Leo groups (n = 36 per group). Flap viability, flap perfusion, and level of protein linked with oxidative stress, cell apoptosis, and angiogenesis were evaluated. RESULTS: Relative to control group, the Leo group showed significantly higher the flap survival percentage (70.5% versus 90.2%, P < 0.05) and blood perfusion (197.1 versus 286.3, P < 0.05). Leo also increased 1.8-fold mean vessel density and upregulated 2.1-fold vascular endothelial growth factor protein expression compared with the control group, both of which indicate increased angiogenesis. Moreover, it significantly inhibited apoptosis by lowering caspase-3 activity. Superoxide dismutase expression was remarkably elevated in Leo group compared with the control group (56.0 versus 43.2 U/mg/protein, P < 0.01), but malondialdehyde quantities were significantly lower in the Leo group compared with control group (41.9 versus 57.5 nmol/mg/protein, P < 0.05). CONCLUSIONS: Leo may serve as an effective drug for improving perforator flap survival in rats via antioxidant and antiapoptotic mechanisms and promotion of angiogenesis.

Effects of bradykinin on the survival of multiterritory perforator flaps in rats.

BACKGROUND: Bradykinin, a vasoactive peptide, has many biological functions. For example, it accelerates angiogenesis. Thus, we studied the effects of bradykinin on the survival of perforator flaps. METHODS: Averagely, 50 male Sprague-Dawley rats were divided into control and bradykinin groups and underwent procedures to the multiterritory perforator flap. Areas of flap survival were tested 7 days later. Flap perfusion was evaluated by laser Doppler imaging. We assessed the extent of autophagy by determining LC3-II/I, Beclin 1, and p62. Flap angiogenesis was assessed by immunohistochemistry and H&E staining. We measured the level of vascular endothelial growth factor (VEGF) protein using western blot. We assessed oxidative stress by measuring the activity of superoxide dismutase (SOD) and malondialdehyde (MDA) levels. The apoptotic index was also evaluated by western blot, and we determined nitric oxide (NO) production using an NO assay kit. RESULTS: The bradykinin group exhibited significantly larger areas of flap survival, higher blood supply, and more neovascularization. The bradykinin group also had higher SOD activity, higher VEGF expression and NO content, and reduced MDA compared to the control group. Rats treated with bradykinin also had lower levels of apoptosis and autophagy relative to the control group. CONCLUSION: Our results suggest that bradykinin promotes the survival of multiterritory perforator flaps by increasing angiogenesis, promoting the release of NO, suppressing apoptosis, reducing oxidative stress, and inhibiting autophagy.

Post-traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: A case report.

Post-traumatic lymphedema is poorly understood. It is rarely considered in limb reconstruction decision-making approach. We report a case of a 41-year-old female who presented with right upper extremity lymphedema after degloving injury and split thickness skin graft, successfully treated with a superficial circumflex iliac artery perforator (SCIP) free flap restoring the lymphatic drainage. Right upper extremity had an excess of 258.7 mL or an excess volume of 27.86% compared to the healthy contralateral limb. A SCIP free flap including lymphatic vessels (SCIP-L) was performed to replace the skin graft in order to restore the lymphatic flow. Flap size was 19 × 8 cm and pedicle length was 4 cm. No lymph nodes were included and no lymphatic or lymphovenous anastomoses were performed. The surgery was uneventful, and there were no postoperative complications. Fourteen days after free tissue transfer, lymphedema showed clear improvement. At a 4-month follow-up, 55.6% reduction of excess volume was obtained. Indocyanine green lymphography performed at that time showed a restitution of lymph flow through the flap. Lymphedema improvements persisted at a 6-month follow-up. A successful treatment of post-traumatic lymphedema can be performed by using the SCIP-L free flap for soft tissue reconstruction of critical lymphatic drainage areas.

Free posterior tibial artery perforator flap for 2-stage tracheal reconstruction in patients after resection of well-differentiated thyroid carcinoma invading the trachea.

BACKGROUND: The present study was conducted to explore the efficacy of using a free posterior tibial artery perforator flap (FPTAPF) for trachea reconstruction after resection of well-differentiated thyroid carcinoma (WDTC) invading the trachea. METHODS: We retrospectively collected and analyzed clinical and surgical data from 14 patients who underwent tracheal reconstruction using a FPTAPF after resection of WDTC invading the trachea between August 2014 and July 2017. RESULTS: Satisfactory tracheal structure and functional recovery were obtained in 11 of the 14 patients. One patient had breathing difficulties after tracheostomy closure tests because of bilateral recurrent laryngeal nerve damage caused by disease invasion. Tracheostomy incision was not closed in 2 patients because they received postoperative adjuvant radioactive iodine 131 treatment. CONCLUSION: Satisfactory tracheal reconstruction results were achieved in patients with resection of WDTC invading the trachea, indicating that a FPTAPF is a safe and reliable choice for management.

Foot reconstruction with the superficial circumflex iliac artery perforator flap under local anesthesia: Two case reports.

RATIONALE: The superficial circumflex iliac artery perforator (SCIP) free flap is a popular method used in foot reconstruction. Although the SCIP flap has a relatively short pedicle and does not require intramuscular dissection, general anesthesia is largely preferred for SCIP flap reconstruction. We report 2 cases with the free SCIP flap for skin and soft tissue reconstruction of the foot under local anesthesia. PATIENT CONCERNS: Case 1 was a 34-year-old man sustained a crush injury to the dorsal foot, resulting in a soft tissue defect with bone and tendon exposure. Case 2 was a 41-year-old man with type 2 diabetes was referred to our division for an intractable ankle wound after surgery for a calcaneal bone fracture. DIAGNOSIS: The diagnosis was intractable wounds on feet caused by trauma and surgery. Patients were unable to receive general anesthesia because of asthma or elevated liver enzymes. INTERVENTIONS: Two patients with tissue defects on their feet were treated with SCIP flaps under local anesthesia. Fifteen milliliter of 0.5% bupivacaine was injected for ankle block. SCIP flaps were harvested after injecting 10 to 15 mL of 1% lidocaine combined with epinephrine around the flap incisions. OUTCOMES: No complications related to the use of local anesthesia developed during the operation or postoperatively. Two flaps survived and fully took without complications. LESSONS: With proper local anesthesia, successful foot reconstruction with a free SCIP flap was possible. This method can be considered a sufficient option for foot reconstruction for patients unable to receive general anesthesia.

Treatment of deep cavities using a perforator-based island flap with partial de-epithelization.

BACKGROUND: The perforator-based island flap is a popular option for defect coverage. In cases with deep cavities, however, the classical island flap may not be a suitable option. By de-epithelization of the peripheral portion of a perforator-based island flap, the distal part of the flap can be used to fill deep spaces, as the flap can be folded and inserted into the spaces. METHODS: From June 2015 to April 2017, 21 cases of deep internal defects were reconstructed with perforator-based island flaps with peripheral de-epithelization. A fasciocutaneous flap was elevated and rotated with the pivot point on the perforator. After performing de-epithelization on the periphery of the flap, the de-epithelized portion of the flap was inserted and anchored into the internal defect. Demographic information about the patients, the size of the defects, the perforators that were used, and complications were recorded. RESULTS: During the follow-up period (mean, 14.2 months) of total 21 cases, no major complications such as flap loss occurred. In 2 cases, a minor complication was observed. Temporary flap congestion was seen in 1 case, and was treated with a short period of leech therapy, and the other case was partial necrosis on the flap margin, which was cured with minimal debridement and conservative treatment. No major problems have occurred, especially on the de-epithelized part of the flap and in the occupied space. CONCLUSIONS: With performing careful procedure, a perforator-based island flap with partial de-epithelization can be a useful option for the surgical treatment of deep cavities. TRIAL REGISTRATION: This study was retrospectively registered in the institutional review board on human subjects research and the ethics committee, Hanyang University Guri Hospital (Institutional Review Board File No. 2018-01-003-002 https://www.e-irb.com:3443/devlpg/nlpgS200.jsp ).

Inhibition of autophagy after perforator flap surgery increases flap survival and angiogenesis.

BACKGROUND: The survival ratio of multiterritory perforator flap is variable. Therefore, surviving mechanisms are increasingly explored to identify novel therapeutics. The condition of the choke zone is essential for perforator flap survival. In this study, we investigated autophagy in the choke zone after flap surgery. MATERIALS AND METHODS: The flap model involved a perforator flap with three territories that was located on the right dorsal side of a rat. A total of 36 rats were divided into six groups, including the control, 0 d postoperative (PO), 1, 3, 5, and 7 d PO groups. In addition, 72 rats were divided into three groups, including a control group, a 3-methyladenine (3-MA) group, and a rapamycin group. Skin tissue of rats was used for measuring autophagy proteins, vascular endothelial growth factor (VEGF) expression, and histological examination. On day 7 after surgery, the survival ratio of each flap was determined. RESULTS: The expression of autophagy and VEGF in the second choke zone (choke II) was increased after flap surgery. Among the three groups, the survival ratio of flaps in the 3-MA group was the highest. Furthermore, the angiogenesis level in the 3-MA group in choke II was the highest among the three groups. CONCLUSIONS: Autophagy was initiated by surgery in choke II, and VEGF expression in choke II was increased after flap surgery. Inhibiting autophagy after perforator flap surgery is beneficial for flap survival and for promoting angiogenesis in choke II.