Successful replantation of amputated facial tissues by supermicrosurgery.

BACKGROUND: Although replantation of amputated facial segments remains challenging in reconstructive surgery, it offers excellent aesthetic and functional outcomes. METHODS: From May 2004 to October 2019, 12 patients underwent replantation of amputated facial tissues by supermicrosurgery. The case details, such as the rationale for replantation, the operation method, and postoperative therapy, are described. Four cases are discussed to demonstrate the replantation of different facial parts. RESULTS: Facial tissue replantation was successful in all 12 patients without secondary surgery. The cases included the nose (1 patient), ears (8 patients), lips (2 patients), and one of the soft tissue segments surrounding the lower jaw. Venous congestion occurred in three patients who received a solitary arterial repair and were treated with bloodletting. All patients expressed satisfaction with the cosmetic and functional results at the final follow-up. CONCLUSIONS: Supermicrosurgical facial tissue replantation is a promising and effective procedure for providing patients with the best aesthetic and functional outcomes.

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.

The strategy for vaginal rejuvenation: CO2 laser or vaginoplasty?

BACKGROUND: Vaginal laxity may result from trauma to the pelvic floor muscle, which may affect patients' sensation and quality of life. Vaginal rejuvenation, including surgical or nonsurgical interventions, aims to improve laxity. In this study, we aimed to establish a strategy for vaginal rejuvenation by comparing surgical and nonsurgical methods. METHODS: A retrospective clinical study was performed on patients who complained about vaginal laxity from 2017 to 2019. The degree of vaginal laxity severity was evaluated by vaginal examination in each patient. The patients were categorized as having a light, moderate or severe degree of vaginal laxity, and different correction methods were chosen accordingly. The Female Sexual Function Index (FSFI) questionnaire was administered to the patients preoperatively and at three months and one year after treatment. RESULTS: Seventeen patients with severe-degree vaginal laxity were treated with vaginoplasty. The total FSFI score was 23.21±2.57 before the operation and significantly increased to 29.36±1.84 (P<0.01) at one year after surgery. Eleven patients with moderate-degree vaginal laxity were treated with vaginoplasty and had a significant improvement in the total FSFI score at one year after surgery (29.86±1.74, P<0.01) compared with the FSFI score before surgery (23.41±2.84). Three patients with moderate-degree vaginal laxity were treated with a CO2 laser and tended to have increased FSFI scores but did not show significant improvement after the operation. CO2 laser treatment was performed on 16 patients with light-degree vaginal laxity. The total FSFI score improved from 23.76±2.35 to 26.16±2.58 at one year (P<0.05). CONCLUSIONS: The strategy for vaginal rejuvenation should be selected based on the degree of vaginal laxity severity. Surgical treatment is suitable for severe- and moderate-degree vaginal laxity while nonsurgical treatment is suitable for light-degree vaginal laxity.

Impact of COVID-19 outbreak on the care of patients with inflammatory bowel disease: A comparison before and after the outbreak in South China.

BACKGROUND AND AIMS: Epidemics pose a great challenge to health care of patients. However, the impact of unprecedented situation of COVID-19 outbreak on health care of inflammatory bowel disease (IBD) patients in real-world setting has seldom been investigated. METHODS: We performed an observational study in a tertiary referral IBD center in China. The mode of health care and medication use was compared before and after COVID-19 outbreak. Electronic questionnaire surveys were performed among gastroenterologists and IBD patients to investigate the impact of COVID-19 outbreak on their attitudes towards telemedicine. RESULTS: COVID-19 outbreak resulted in substantial decrease of patients participating in standard face-to-face visit during 1 month post-outbreak (n = 51) than pre-outbreak (n = 249), whereas the participation in telemedicine was significantly higher than comparable period in 2019 (414 vs 93). During the 1 month after COVID-19 outbreak, 39 (39/56, 69.6%) patients had their infliximab infusion postponed with the mean delay of 3 weeks. The immunomodulator use was similar between pre-outbreak and post-outbreak. Six elective surgeries were postponed for a median of 43 days. In post-outbreak period, 193 (193/297, 64.98%) of the surveyed physicians have used telemedicine with an increase of 18.9% compared with 46.13% (137/292) in the pre-outbreak period (P < 0.001); 331 (331/505, 65.54%) of the surveyed IBD patients supported that the use of telemedicine should be increased in future health care. CONCLUSION: COVID-19 outbreak resulted in a great change in health-care access among IBD patients including decrease in standard face-to-face visit and delay of biologics use. There was an increased use and need of telemedicine after COVID-19 outbreak.

Impact of COVID-19 on the Healthcare of Patients With Inflammatory Bowel Disease: A Comparison Between Epicenter vs. Non-epicenter Areas.

Background and Aims: The COVID-19 pandemic poses a great challenge to healthcare. We aimed to investigate the impact of COVID-19 on the healthcare of patients with inflammatory bowel disease (IBD) in epicenter and non-epicenter areas. Methods: Patients with IBD from Hubei province (the epicenter of COVID-19) and Guangdong province (a non-epicenter area), China were surveyed during the pandemic. The questionnaire included change of medications (steroids, immunomodulators, and biologics), procedures (lab tests, endoscopy, and elective surgery), and healthcare mode (standard healthcare vs. telemedicine) during 1 month before and after the outbreak of COVID-19. Results: In total, 324 IBD patients from Guangdong province (non-epicenter) and 149 from Hubei province (epicenter) completed the questionnaire with comparable demographic characteristics. Compared to patients in Guangdong province (non-epicenter), significantly more patients in Hubei (epicenter) had delayed lab tests/endoscopy procedures [61.1% (91/149) vs. 25.3% (82/324), p < 0.001], drug withdrawal [28.6% (43/149) vs. 9.3% (30/324), p < 0.001], delayed biologics infusions [60.4% (90/149) vs. 19.1% (62/324), p < 0.001], and postponed elective surgery [16.1% (24/149) vs. 3.7% (12/324), p < 0.001]. There was an increased use of telemedicine after the outbreak compared to before the outbreak in Hubei province [38.9% (58/149) vs. 15.4% (23/149), p < 0.001], while such a significant increase was not observed in Guangdong province [21.9% (71/324) vs. 18.8% (61/324), p = 0.38]. Approximately two-thirds of IBD patients from both sites agreed that telemedicine should be increasingly used in future medical care. Conclusions: Our patient-based survey study in a real-world setting showed that COVID-19 resulted in a great impact on the healthcare of patients with IBD, and such an impact was more obvious in the epicenter compared to the non-epicenter area of COVID-19. Telemedicine offers a good solution to counteract the challenges in an unprecedented situation such as COVID-19.

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.

Preferred Experience of Modifications to Emergency Surgical Treatment for Total Scalp Avulsion With Halo-Vest Head Ring and Quick Hair Removing.

BACKGROUND: Total scalp avulsion is a fairly rear but severe soft tissue injury. Even with microsurgical replantation, the survival rate is still low. In this study, the authors incorporated 2 main modifications (Halo-Vest head ring and quick hair removing) and assessed the surgical outcomes versus those of traditional replantation. METHODS:: Eighteen patients were included in the study who suffered from total scalp avulsion. After consideration of the outcomes from the first 7 patients, the authors modified our surgical procedures and introduced the use of Halo-Vest head ring and quick hair removing in the treatments for the rest 11 patients. The surgical outcomes with both approaches were observed and compared, including the operation time and incidence of scalp necrosis. RESULTS:: The mean debridement time was 3.5 hours in traditional treatment versus 1.68 hours in modified treatment. The mean operative time was 11.14 hours in traditional treatment versus 8.05 hours in modified treatment. After the replantation, in those 7 patients without modifications, there was 1 total scalp necrosis and 6 partial scalp necrosis. In those 11 patients with modifications, there was 1 total scalp necrosis and 1 suffered a partial scalp necrosis, while the scalp survived well in other 9 patients. Classical cases with modified or traditional methods were reported respectively. CONCLUSION: The application of Halo-Vest head ring and quick hair removing provides a reliable method to treat total scalp avulsion. It is safe, technically easy and worth being widely used in the clinical application.

Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female-to-male transsexuals?

PURPOSE: Construction of a neourethra is always considered to be a difficult part in phalloplasty, especially for the female-to-male (FTM) transsexual patients. We report our experience with prefabricated pars pendulans urethrae using vaginal mucosal graft for phalloplasty in FTM transsexuals. MATERIALS AND METHODS: We retrospectively reviewed notes on the 22 FTM patients treated with pedicled-flap phalloplasty with prefabricated pars pendulans urethrae using vaginal mucosal graft between January 2008 and December 2012. Surgical outcome, urological function, and complications were recorded. Histological difference between normal mucosa and skin, and pathological changes of vaginal mucosal graft were also observed. RESULTS: All the reconstructive penis survived, and patients could void in a standing position finally at a median follow-up of 25.4 ± 6.0 months. Urethral fistula and urethral stricture rates were 31.8 % (7/22 patients) and 4.5 % (1/22 patients), respectively. The occurrence of the urethral stricture was remarkably low compared with previous reports. Our histological results also showed a pronounced similarity between vaginal and buccal mucosa. Morphologically, they resembled urethral epithelium more closely than the forearm skin. Following the free transfer, the vaginal mucosal graft also showed a good revascularization and the inflammatory reaction and the extent of fibrosis of the mucosa decreased to the normal level after a 6-month prefabrication. CONCLUSION: With prefabrication of vaginal mucosal graft, we reconstruct a competent phallic neourethra in these FTM transsexuals. According to its histological similarities and source character, the vaginal mucosa is the excellent substitute material for promising urethral reconstruction in FTM transsexuals.

Preconstruction of the Pars Pendulans Urethrae for Phalloplasty with Digestive Mucosa Using a Prefabricated Anterolateral Thigh Flap in a One-arm Patient.

SUMMARY: We herein report a successful preconstruction of the pars pendulans urethrae with the ileum mucosa for phalloplasty in a one-arm patient using a prefabricated anterolateral thigh flap. After a 2-stage operation and an 18-month follow-up, the patient achieved a good postoperative appearance and an excellent function of neophallus. We believe the use of digestive mucosa for urethral reconstruction enlightens us and deserves further comprehensive clinical studies.

Facial reanimation by one-stage microneurovascular free abductor hallucis muscle transplantation: personal experience and long-term outcomes.

BACKGROUND: In 1990, Jiang Hua introduced a new method using one-stage reconstruction with free abductor hallucis muscle transfer for dynamic reanimation of established unilateral facial paralysis. The authors present their experience with this procedure and analyze the postoperative complications and long-term functional and aesthetic outcomes. METHODS: From March of 1990 to March of 2010, 45 patients underwent the free abductor hallucis muscle transfer procedure in the authors' department. Forty-one were followed up for 54.6 months (range, 28 months to 17 years). The Toronto Facial Grading System and Facial Nerve Function Index were used to evaluate facial nerve function at 2 years after surgery and last follow-up. Complications and function of the donor foot were analyzed. RESULTS: No postoperative mortality was found. Complications occurred in four of 41 patients, including muscle loss, infection, hematoma, and hypertrophic scar. The others obtained satisfactory symmetric faces in the static state and in voluntary contraction of the transferred muscles. Mean values for the Toronto Facial Grading System (50.6±7.8) and the Facial Nerve Function Index (65.7±11.4 percent) were significantly higher at 2 years postoperatively in comparison with preoperative status (21.2±5.3 and 19.5±3.6 percent, respectively) (p<0.05). Long-term outcomes (Toronto Facial Grading System, 54.8±6.9; Facial Nerve Function Index, 79.4±9.6 percent) were awarded higher values than early outcomes shown at 2 years postoperatively (p<0.05). CONCLUSIONS: Free abductor hallucis muscle transfer is safe and effective in dynamic reanimation of longstanding unilateral facial paralysis. Favorable long-term results demonstrate that the authors' technique is an alternative method for facial reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Profiling of innervations of mimetic muscles in fresh human cadavers using a modified Sihler's technique.

The nerve map of the human face, although important in guiding facial surgery, has not been well defined. In this study we applied a modified Sihler's technique to profile intramuscular innervation of human mimetic muscles. Six fresh cadaveric heads were used. The intramuscular distribution of the facial nerve in human mimetic muscles was visualized using a modified Sihler's technique. Modified Sihler's staining revealed a three-dimensional picture of the clearly purple-black intramuscular facial and sensory nerves. The nerve branching patterns of both facial halves were asymmetrical. None of the fine nerve branches crossed over the midline. The facial nerve branches divided into secondary rami and formed a mesh-like plexus before entering the target muscles at a right angle. The modified Sihler's technique can profile intramuscular innervation of human mimetic muscles. Our nerve map of the face offers valuable guidance for facial reanimation surgery, facial cosmetic surgery, and parotid surgery.

[MAFbx and MuRF1 mRNA expression and its relationship with muscular contractility following free muscle transfer].

OBJECTIVE: To study muscle atrophy F-box (MAFbx) and muscle ring finger 1 (MuRF1) mRNA expression and its relationship with muscular contraction following free muscle transfer. METHODS: The gracilis muscle was orthotopic transferred in adult rat to establish the animal model. The muscle at the unoperated side was used as control. The expression of MAFbx and MuRF1 mRNA, the muscle contraction and muscle function were measured by real-time PCR and multiple function physiological device. The relationship among the expression of MAFbx and MuRF1 mRNA, the muscle contraction and muscle function was analyzed. RESULTS: After muscle free transfer, muscle wet weight reservation, the maximum contraction and tetanus strength reduce first and increased later, but still lower than those at control side. The expression of MAFbx and MuRF1 mRNA reached peak level 3 - 4 weeks after muscle transfer which was 7.1 and 4.1 times as that at control side. It decreased later, but still higher than that at control side, showing a significant difference between them (P< 0. 05). CONCLUSIONS: Persistent over-expression of MAFbx and MuRF1 mRNA after muscle transfer has a close relationship with muscle atrophy and muscle dysfunction. MAFbx and MuRF1 can be used as markers for early muscle atrophy, and also as potential target for drug treatment of muscle atrophy.

[Morphologic observation of the regenerated nerve in reconstructed penis with sensory nerve implantation in rabbit].

OBJECTIVE: To investigate the mechanism of sensory nerve regeneration of the reconstructed penis with sensory nerve implantation and to explore a new surgical technique to improve the postoperative sensory function in phallic reconstruction. METHODS: Adult male New Zealand rabbits were randomly divided into experimental group (n = 20, with sensory nerve implantation) and control group (n = 20, without sensory nerve implantation), which were both performed phalloplasty with a superficial epigastric faciovascular pedicle flap. Postoperatively, the nerve regeneration process of the reconstructed penis was observed histologically. RESULTS: In experimental group, the amount of CGRP positive nerve fibers increased markedly with the time prolonged, whereas merely a few CGRP positive fibers scattered in deep dermis 6 months later in the other group. The cutaneous sensory nerve regeneration of the reconstructed penis in experimental group shows the procedure that the myelinated axon began to exist within 3 months, thereafter the myelinated axon and unmyelinated axon were both observed under the electron microscope. CONCLUSION: These findings show that the rabbit model of phalloplasty with sensory nerve implantation can acquire well sensory reinnervation, and bring a light to clinical application for restoration of sensory function in reconstructed penis.

[Anatomy of buccal and marginal mandibular branches of facial nerve and its clinical significance].

OBJECTIVE: To study the course and distribution of buccal and marginal mandibular branches of facial nerve, and its relevance to the treatment of facial paralysis and the protection of facial nerve during surgery. METHODS: 12 cadaver heads were dissected (24 specimens). The course of the buccal and marginal mandibular branch and the interconnections between them were observed. The relationship of buccal branch to parotid duct, marginal mandibular branch to the inferior border of mandible were studied. With modified Sihler's staining technique, the distribution of facial nerve branches in innervated mimetic muscles was displayed. These anatomic relationships mentioned above were further confirmed during the operation of 40 patients with facial paralysis. RESULTS: Parotid duct had a constant surface landmark. Buccal branch mainly consisted of 2-3 ramifications in 87.5% of the specimens, while marginal mandibular branch was double or single in 95.9% of the specimens. The buccal branch coursed within the distance between 10.7 mm above and 9.3 mm below the parotid duct, and innervated mimetic muscles of midface. The marginal mandibular branch coursed within the distance between 13.4 mm above and 4.8 mm below the lower border of mandible, crossed superiorly the facial artery and innervated mimetic muscles of lower lip. CONCLUSIONS: There is a close relationship of buccal branch to parotid duct and marginal mandibular branch to facial artery and lower border of mandible. With modified Sihler's staining technique, the original 3-dimensional picture of the intramuscular nerve distribution in human mimetic muscles.

[Location of somatic sensory neurons of the skin and dorsal nerve of the penis in rabbits].

OBJECTIVE: To trace the segmental distribution of somatic sensory neurons of the skin and dorsal nerve in the rabbits penis. METHODS: The experiment was performed on 8 adult male rabbits with the nerve tracing method of retrograde axonal transport of horseradish peroxidase (HRP), which was injected into the dermis around the penis and the dorsal nerve of the penis. The rabbits were sacrificed five days later to harvest the spinal cord segments and the dorsal root ganglia of lumbosacral segments for histological study. RESULTS: The HRP tracing showed that a number of labeled HRP positive neurons appeared in spinal ganglia (S2 - S4) in all the rabbits, and distributed segmentally. The counts of the positive neurons different segments were: S2 (215.0 +/- 10.2) , S3 (242.2 +/- 8.3) and S4 (109.7 +/- 8.4) respectively, with statistically significant difference between the two groups. CONCLUSION: The rabbit's sensory nerve fibers in both the skin and the dorsal nerve of the penis are rooted in the S2-S4 segments of spinal ganglia, which distribute regularly.

[Transfection of agrin gene on the recovery of muscle function after free neurovascular muscle transfer].

OBJECTIVE: To investigate the effects of transfection of agrin gene on the recovery of muscle function after a free neurovascular muscle transfer. METHODS: The electrical gene transfection was performed when the gracilis muscle of the SD rat was completed free neurovascular transfer. The experimental group was treated with pCS2+ -agrin, the group with plasmid pCS2+ as the negative control and the group with normal saline as the frank control. The muscle function, expression of neural agrin and the junctional nAChR number was measured after the operation. RESULTS: At 4, 5 and 10 weeks postoperatively, the pCS2+ -agrin group was significantly better than the control groups in muscle function (P < 0.05 ). The immunohistochemical staining showed an increasing deposition of the agrin protein near the endplate at 1 and 5 weeks after the operation, but decreasing remarkably to the level of control groups at 10 weeks postoperatively. The pCS2+ -agrin group was significantly more than the control groups in junctional nAChR number at every points of the time postoperatively. CONCLUSIONS: Transfection of agrin gene in the transferred muscle may increase the early recovery of muscle function.

[Changes of acetylcholine receptor distribution at the motor end-plates following muscle transfer].

OBJECTIVE: To investigate the changes of acetylcholine receptor (AChR) distribution at the neuromuscular junction (i.e. motor end-plate) following the free neurovascular muscle transfer. METHODS: AChR in the gracilis muscle of the Wistar rat following free neurovascular transfer were labeled by fluorescent alpha-bungarotoxin and radioiodinated alpha-bungarotoxin. Then confocal microscope and gamma-counting were estimated to ACHR, qualitatively and quantitatively. RESULTS: The junctional AChR numbers decreased to a minimum at the fourth week postoperatively, whereas the extrajunctional receptor numbers increased. From the fifth week postoperatively, the number of junctional AChR's increased. Even at 30 weeks after transfer, the morphology of the neuromuscular junction failed to return to the preoperative style. The number of acetylcholine receptors at the reinnervated neuromuscular junction also remained lower than the control. CONCLUSION: The persistent weakness following free neurovascular muscle transfer may be attributed to these qualitative and quantitative changes at the neuromuscular junction.