[Serial reconstruction strategy for severe cervical cicatrix deformity].

OBJECTIVE: To explore serial reconstruction strategy for severe cervical cicatrix deformity. METHODS: A total of 24 cases, III or IV degree cervical contracture deformity, were treated in Shanghai Ninth People's Hospital from January 2006 to December 2011. There were 18 males and 6 females with an average age of 35.4 years. The etiologies included burns, chemical injuries and scalding. Three evaluation indices of mental cervical angle (MCA) including soft tissue MCA, osseous MCA and dynamic MCA were measured before treatment and during follow-ups. The first-stage treatment was comprised of cervical cicatrix resection, contracture release, lift of dual direction platysma flap, reconstruction of MCA and skin grafting. At Months 3-6, second-stage treatment was performed, including lower mandible scar resection, correction of lower lip eversion, lower mandible region reconstruction with free (para-) scapular skin flap. After two-stage treatment, the patients underwent periodical re-evaluations for gross appearance, function and measurement of MCA. RESULTS: Twenty-two patients completing two-stage reconstruction were followed up. Notable improvement of cervical mobilization and contour were achieved. Soft tissue MCA decreased from 130° ± 34° to 110° ± 24°, osseous MCA increased from 71° ± 23° to 95° ± 19° and dynamic MCA increased from 25° ± 18° to 80° ± 26°. CONCLUSIONS: The serial treatment strategy is effective. In comparisons with reconstruction with skin graft only or skin flap only, the strategy possesses many advantages.

Immediate repair of major abdominal wall defect after extensive tumor excision in patients with abdominal wall neoplasm: a retrospective review of 27 cases [corrected].

BACKGROUND: The treatment of abdominal wall neoplasm continues to present a challenging problem because it is not easy to repair the giant defect which is resulted from extensive tumor excision. Some techniques and materials have been reported, but most report a certain technique or material for abdominal wall reconstruction. Therefore, we retrospectively reviewed the treatment of such patients in our department and assessed the reconstruction algorithm in such a situation. METHODS: We studied 27 patients undergoing immediate abdominal wall reconstruction between 1999 and 2008 who sought care for major defects after extensive tumor excision of malignancy. We categorized the defects into three types: type I, defects involving only the loss of skin (15 cases); type II, myofascial defects with intact skin coverage (6 cases); and type III, myofascial defects without skin coverage (6 cases). Different techniques and materials were used. Postoperative morbidities, sign of herniation, and other follow-up data were recorded. RESULTS: The immediate abdominal wall reconstruction was successful in all patients. There was no severe morbidity after the operation. Only one patient developed hernia. CONCLUSIONS: Most type I defects can be corrected with primary suture. For type II defects, a prosthetic or biological mesh, or alternatively an autologous fascial substitute, may be used. For type III defects, the resulting full-thickness defect will require a myocutaneous flap, such as the tensor fascia lata flap, with or without a mesh for abdominal wall reconstruction. Human acellular dermal matrix, a biological mesh, is an ideal alternative for synthetic mesh, especially in situations of infection or contamination.

[Anatomy and clinical application of posterior calf fasciocutaneous flap].

OBJECTIVE: To investigate the blood supply and the clinical application of the posterior calf fasciocutaneous flap for repairing the frontal defect of knee joint. METHODS: Based on the article review and the anatomical study of the posterior calf in 8 cadavers (16 sides), 10 cases with frontal defects of knee joints were repaired with island fasciocutaneous flaps which had pedicles of lateral superficial sural artery and the lateral sural nerve. RESULTS: The anatomical study showed there were three systems of superficial sural blood supply- medial, middle and lateral systems. They are originated from popliteal artery or from the bilateral sural artery. The lateral superficial sural artery was present in 100% of the cadavers. The flaps survived completely in 9 cases, except one case with partial necrosis at the one-fourth distal end of the flap. The patients were followed up for 6-12 months with good aesthetic and functional results. CONCLUSIONS: The posterior calf island fasciocutaneous flap has an reliable blood supply and protective sense nerve. The flap is ideal for the reconstruction of soft tissue defect around knee joint.

Reconstruction of the abdominal wall by using a combination of the human acellular dermal matrix implant and an interpositional omentum flap after extensive tumor resection in patients with abdominal wall neoplasm: a preliminary result.

AIM: To present our trial using a combination of the human acellular dermal matrix (HADM) implant and an interpositional omentum flap to repair giant abdominal wall defects after extensive tumor resection. METHODS: Between February and October of 2007, three patients with giant defects of the abdominal wall after extensive tumor resection underwent reconstruction with a combination of HADM and omentum flap. Postoperative morbidities and signs of herniation were monitored. RESULTS: The abdominal wall reconstruction was successful in these three patients, there was no severe morbidity and no signs of herniation in the follow-up period. CONCLUSION: The combination of HADM and omentum flap offers a new, safe and effective alternative to traditional forms in the repair of giant abdominal wall defects. Further analysis of the long-term outcome and more cases are needed to assess the reliability of this technique.

[Clinical analysis of complications of polyacrylamide hydrogel injection for augmentation mammoplasty in 118 cases].

OBJECTIVE: To analyze the clinical manifestations and explore suitable treatments for the complications induced by polyacrylamide hydrogel(PAHG) injection for augmentation mammoplasty. METHODS: The symptoms, physical signs and treatments of the 118 cases were analyzed and summarized. RESULTS: The complications included in nodule formation (54.2%), pain (33.9%), PAHG migration (7.6%) and acute mastitis in lactation (4.3%). Satisfactory clinical treatment results have been obtained after suitable treatments. CONCLUSIONS: The complications induced by PAHG injection for augmentation mammoplasty have increased following its widely use, the re-evaluation for this technique should be made, and more effective treatment should be considered.

[Microvascular nasal repair using a reversed superficial temporal artery auricular flap.].

OBJECTIVE: A reversed superficial temporal artery auricular flap was presented to explore a new method for reconstructing the defects of the distal nose by microsurgical techniques. METHODS: A reversed superficial temporal artery auricular flap had been used on fifteen patients with nasal defects, including thirteen patients with alar defects and two patients with nasal tip defects. The reversed superficial temporal vessels of the flap were anastomosed with the recipient facial vessels. The size of the flap was 2.5 cm x 2. 0 cm - 4.0 cm x 2.5 cm, the length of the vascular pedicle was 5 - 8 cm, average 6.5 cm RESULTS: The flap survived uneventfully in all fifteen patients. RESULTS: demonstrated satisfactory symmetry between the reconstructed ala and the contralateral side as well as an excellent tip projection. The donor-site defect was minimal. CONCLUSIONS: The reversed superficial temporal artery auricular flap offers an adequate length of vascular pedicle of the flap, it delivers a good solution to the problem of the vascular pedicle shortage of the proximal superficial artery auricular flap. This technique may become the top choice in the microvascular auricular transfer.

[Construction and clinical application of tissue engineered epidermal membrane].

OBJECTIVE: To Construct tissue engineered epidermal membrane for promoting healing of clinical skin graft donor site wound. METHODS: Epidermal cells /Chitosan-Gelatin (CG) membrane was constructed with cultured human epidermal cells(EC) and CG membrane, at the donor site of split skin graft, the wound was divided into three groups: the control group was covered with CG membrane without KC, KC/CG membrane was grafted on the treatment part of the wound area, and blank group was covered with traditional vaseline gauze. The engineered epidermal membrane and its effect on wound were evaluated with gross observation, HE, immunohistochemistry, collagen type I/III ratio by picrosirius polarization method and RT - PCR test at various time points before and after operation. RESULTS: The result showed that human tissue engineered epidermis could be constructed with cultured human EC and CG membrane, and this artificial epidermal membrane could be used for promoting the healing of skin graft donor site wound successfully (16 cases with 3 months' oberservation). The average healing time is (16.2 +/- 3.8) days for control group, (8.1 +/- 1.3) days for experimental group and (23.0 +/- 5.7) days for blank group. The artificial epidermis was well survived with normal structure. In addition, less hypertrophic scar development was observed in treated wound at 90 days (3 in 16 cases, 20.0%) than in the blank sites (11 in 16 cases, 74.4%). The difference is statistically significant (chi2 = 8.127, P < 0.01). CONCLUSIONS: The constructed EC-CG membrane can be constructed in vitro, survived in vivo and has good clinical application in promoting healing of skin graft donor site wound and inhibiting hypertrophic scar formation.

[Microsurgical reconstruction of the nasal subunit defects].

OBJECTIVE: The nose is composed of several delicate subunits, some of which are difficult to reconstruct if they have been injured. The paper presents the microsurgical technique to repair the nasal subunit defects with the free combined preauricular and auricular flap which well match the nasal tissues in texture, contour and color. METHODS: The nasal subunit defects were repaired with the combined preauricular and auricular flap which were vascularized by the superficial temporal vascular system. The flap was harvested from the contralateral preauricular and the region of helix crus. The superficial temporal vessels were anastomosed to facial vessels via the vascular grafts harvested from the lateral circumfluent femoral vessels, which were about 10 to 14 cm in length. The helix crus of donor ear was reconstructed with the post-auricular flap. RESULTS: 28 cases were treated, including 3 cases of nasal tip defects, 9 cases of combined nasal alar and sidewall defects, and 16 cases of nasal alar defects. In these cases, the size of the subunit defects varied from 2.5 cm x 1.5 cm to 4 cm x 2.5 cm. 27 cases were successfully repaired with satisfactory results. The contour of reconstructed helix crus in donor site was acceptable. No walking dysfunction of the donor thigh was complained. There is one failed case, and the possible reason is the insufficient blood perfusion to the flaps, which may due to the patient's longtime-smoking status and the hypertension. CONCLUSIONS: The technique of free combined preauricular and auricular flap is ideal for the reconstruction of nasal subunit defects.

[Application and review of the reversed posterior interosseous artery flap in 78 clinical cases].

OBJECTIVE: To assess and review the indications and methods of the reversed posterior interosseous artery flap for repairing soft tissue defects of the hand. METHODS: In the series, three types of flaps were utilized including the reversed posterior interosseous artery flap, the expanded reversed posterior interosseous artery flap and the reversed posterior interosseous artery conjoint flap. 78 clinical cases were treated with this method, in which 12 cases used the expanded reversed posterior interosseous artery flap and 10 cases used the reversed posterior interosseous artery conjoint flap. The flap,ranged from 8 approximately 6 cm to 14 approximately 8 cm, was used to repair the defects of the dorsal hand as far as to the fingerweb. The anatomy of the posterior interosseous artery was observed in the surgical dissection. RESULTS: The posterior interosseous artery was consistently identified in all the 78 cases. In 4 cases, the artery terminated in the middle third of the dorsal forearm, therefore an alternative method of reconstruction was used. In the 53 cases of reversed posterior interosseous flaps, 49 cases healed uneventfully and 4 cases suffered necrosis in the distal border of the flap, but subsequently healed spontaneously. 12 cases of expanded flaps survived well and the donor sites were directly approximated. In the 9 cases of conjoint flaps based on the posterior interosseous artery, 7 cases healed uneventfully and 2 cases suffered delayed healing because of flap necrosis of the distal part. The satisfactory appearance and hand function were achieved postoperatively in all cases. CONCLUSIONS: The flap is a better choice for repairing the soft tissue defects of the hand. The different type of flaps can be selected to meet the clinical requirements of reconstruction. It is suggested that the artery variation should be assessed preoperatively.

[Effects of hVEGF cDNA on random skin flap via a replication-deficient adenovirus vector].

OBJECTIVE: The purpose of this study was to determine the effects of local delivery of vascular endothelial growth factor( VEGF) transferred with adenovirus-mediated gene on the survival of ischemic random skin flap in rats. METHODS: The animals were divided into three groups randomly (n = 10) . A 2 cm x 8 cm dorsal skin flap was designed with the pedicle at the level of the iliac crest. In group A (AdCMV-VEGF), each animal received 10(12) PR replication-deficient recombinant adenovirus (AdCMV-VEGF) in the distal two-thirds of the proposed flap by means of the subdermal injection at ten different locations. In group B (AdCMV-GaI), each received 1012 PR AdCMV-Gal. In Group C (Saline), each received 1 ml saline. Three days after the treatment, the flap was elevated as planed way and re-sutured back to its donor site. All the animals were evaluated 7 days after the operation. RESULTS: The mean percentage of surviving flap area was (85.91 +/- 2.54)% in group A, (59.56 +/- l.18)% in group B, and (61.48 +/- l.09)% in group C. There was a significant increase in the percentage of the survival area in the flaps of the group A, compared with the group B and group C (Group B vs. Group A, P < 0.01; Group C vs.Group A, P < 0.01, Group B vs. Group C, P >0.05). Hybridization in the situ, the immunohistochemical stain showed that the VEGF was expressed in the survival tissue of the flap treated with the AdCMV-VEGF, but it was not found in the control groups. Histological analysis demonstrated qualitatively greater amount of granulation tissue and angiogenesis was found in the group treated with the AdCMV-VEGF than the controls. CONCLUSIONS: The results may indicate that Ad vector carrying VEGF cDNA could be useful in enhancing the survival of the skin flap due to the effect of the local delivery of the VEGF.

[Nasal alar reconstruction with a vascularized free auricular composite flap].

OBJECTIVE: The plastic surgeons prefer to reconstruct nasal alar with free auricular composite flap because it well matches nasal tissue in contour, texture and color. However, the size of the free composite flap should be less than 1. 0 cm x 1.5 cm due to the limitation of revascularization. Our aim is to search for a surgical method which could be used to repair full-layer larger nasal alar defects. METHODS: A surgical technique was presented to repair nasal alar defect with a free auricular composite flap, which was vascularized by branches of superficial temporal artery. Briefly, the contralateral auricular composite tissue pedicled by superficial temporal vessels (3 to 4 cm in length) was harvested from region of helix crus and preauricular skin, which matched the arc of the nasal rim, and then transplanted onto the recipient area. The superficial temporal vessel pedicles were anastomosed to facial vessels via vessel grafts harvested from lateral circumflex femoral vessels, which were about 10 to 12 cm in length. RESULTS: Twelve cases were treated, among them, 11 cases were successfully repaired with satisfactory results, one case failed, possibly due to the bad condition of the patient's blood vessels. In our cases, the size of alar defect varied from 1.5 cm x 2.5 cm to 2.0 cm x 3.8 cm. The minimal auricular donor site deformities and inconspicuous scar were acceptable and could easily be hidden by hair. CONCLUSIONS: The technique of free auricular composite flap, which is vascularized by superficial temporal vessels, is ideal for nasal alar reconstruction.

[Experience for reconstruction of defects of abdominal wall with Gore-tex].

OBJECTIVE: To evaluate the outcome of prevention of abdominal hernia in reconstruction of defect of abdominal wall with Gore-tex clinically. METHODS: Six cases of the large defects of abdominal wall were repaired with Gore-tex after surgical removal of abdominal wall tumor. RESULTS: The reconstructed cases were followed up six months to three years and there was no postoperative complication. CONCLUSION: Gore-tex is a reliable and effective biomaterial for reconstruction of the large defect of abdominal wall.

Effect of adenovirus-mediated gene transfection of vascular endothelial growth factor on survival of random flaps in rats.

OBJECTIVE: To evaluate the effect of local application of vascular endothelial growth factor (VEGF) via adenovirus-mediated gene transfer on survival of full thickness flaps selected randomly in rats. METHODS: Thirty Sprague-Dawley rats weighing 480-520 g were used in this study. A dorsal flap (8 cm x 2 cm) in full thickness with the pedicle located at the level of the iliac crest was designed. Then the rats received 1,012 pfu replication-deficient recombinant adenovirus carrying VEGF (AdCMV-VEGF group, n=10), 1,012 pfu recombinant beta-galactosidase adenovirus (AdCMV-Gal group, n=10) and 1 ml saline (saline group, n=10), respectively, in the distal two thirds of the proposed flap by means of subdermal injection at 8 different locations. Three days after treatment, the flaps were elevated as originally designed and sutured back in situ. The survival rate of the flaps was evaluated on day 7 after operation. RESULTS: The survival rate of the flaps in the AdCMV-VEGF group increased significantly as compared with those of the AdCMV-Gal group (P<0.01) and the saline group (P<0.01). Immunohistochemical staining showed that VEGF was expressed in the survival flaps injected with AdCMV-VEGF. Histological analysis showed that more granulation tissues and angiogenesis were observed in the AdCMV-VEGF group than those in the AdCMV-Gal and the saline groups. CONCLUSIONS: Local application of adenovirus-mediated VEGF165 cDNA may efficiently improve the survival of ischemic skin flaps.

[Intra-uterine model of cleft lip and scarless wound healing of fetal rats].

OBJECTIVE: To properly evaluate the benefits of in utero repair of cleft lip, an animal model of cleft lip was developed and the fetal scarless wound healing was observed in SD rat fetus. METHODS: Through a maternal celiotomy and hysterotomy, twenty excisional cleft was created in the upper lip of rat fetus. Another group of 20 rat fetus were given full-thickness incisional wounds in the upper lips. The fetus with cleft lip were returned into utero for further development till birth.Wound specimens from the incisional wounds in the other group were removed successively 12, 24, 48, 72h postwounding for histological examination. RESULTS: The fetus with excisional wound demonstrated a complete cleft lip after birth. In contrast, the wound in the fetus with incisional wounds regenerated with normal architecture histologically, indistinguishable from the surrounding normal skin. CONCLUSION: The results of this preliminary study indicates that the fetal rat cleft lip is technically feasible with an excellent survival rate. Healing occurs without scar formation. This model will be used to document facial growth following in utero repair of a cleft lip.