[Application of body temperature rinse in percutaneous transforaminal endoscopic lumbar discectomy through intervertebral approach].

OBJECTIVE: To investigate the effects of two types of temperature rinses on body temperature, inflammatory cytokine levels, and bleeding volume in percutaneous endoscopic lumbar discectomy. METHODS: Eighty patients underwent percutaneous endoscopic lumbar discectomy from January 2018 to December 2020 were selected and divided into experimental group (40 cases) and control group(40 cases). In experimental group, there were 19 males and 21 females, aged (38.8±9.8) years old;7patients on L4,5 and 33 patients on L5S1;Body msss index(BMI) was (27.8±7.2) kg·m-2. In contral group, there were 18 males and 22 females, aged (41.5±10.9) years old, 5 patients on L4,5 and 35 patients on L5S1;BMI was (26.4±6.2) kg·m-2. The patients in the control group were received normal saline rinse at room temperature, and the patients in the experimental group were received normal saline rinse heated to 37 ℃. Body temperature, chills, nausea, vomiting, and other adverse reactions were recorded. The levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and interleukin-10 (IL-10) in two groups were recorded before and 2 hours after operation. Visual analogue scale (VAS) was used to evaluate the degree of lumbar pain in two groups before and 2 hours after surgery. Fibrinolytic-coagulation indexes with preoperative and 2 hours after surgery, including the D-dimer (DD), fibrinogen degradation products (FDP), activated partial thrombin time (APTT) and prothrombin time (PT) were recorder. Operation time and blood loss in two groups were recorded. RESULTS: The body temperature of both groups showed a downward trend, while the body temperature of the control group was lower than that of the experimental group. The levels of TNF-α, IL-6 and IL-10 in two groups were increased 2 hours after surgery compared with those before surgery(P<0.05), while the levels in experimental group were lower than those in control group(P<0.05). Postoperative VAS in experimental group 2.19±1.13 was significantly lower than that in the control group 3.38±1.35(P<0.05). The levels of DD and FDP at 2 hours after surgery in both groups were higher than those before surgery (P<0.05), while the levels of DD and FDP in the experimental group were higher than those in the control group (P<0.05). There was no significant difference in APTT and PT levels between two groups after operation (P>0.05). The blood loss in the experimental group of (45.2±14.1) ml was lower than that in the control group of (59.52±15.6) ml. The operation time of experimental group (46.7±13.8) min was less than that of control group (58.3±15.2) min(P<0.05). CONCLUSION: Body temperature rinse can reduce the incidence of adverse reactions, alleviate local inflammatory reactions, reduce intraoperative blood loss and shorten the operation time.

Combination of percutaneous endoscopic lumbar discectomy and platelet-rich plasma hydrogel injection for the treatment of lumbar disc herniation.

OBJECTIVE: To determine the safety and efficacy of percutaneous endoscopic lumbar discectomy (PELD) combined with platelet-rich plasma (PRP) hydrogel injection in patients with lumbar disc herniation (LDH). METHODS: A total of 98 consecutive patients with LDH who underwent either PELD combined with PRP hydrogel injection or PELD alone were reviewed. This retrospective study was performed between January 2019 and January 2021. Clinical outcomes were compared in the visual analog scale (VAS) for low back pain and leg pain, Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) scores, and Macnab criteria. Intervertebral disc height on MRI was measured, and the Pfirrmann grade classification was used pre-operatively and post-operatively. RESULTS: No severe adverse events were reported during an 18-month follow-up period. VAS scores for back pain were decreased at 1 month, 3 months, and 18 months in the treatment group than that in the control group. JOA score and ODI in the treatment group at 3-month and 18-month follow-up was lower than that in the control group (P < 0.05). The excellent and good rate of the Macnab criteria was 92.0% (46/50) in the treatment group and 89.6% (43/48) in the control group (P > 0.05). The comparison of Pfirrmann grading and disc height at 18-month follow-up showed significant difference in two groups (P < 0.05). The recurrence of LDH in the treatment group was lower than that in the control group (P < 0.05). CONCLUSIONS: We suggest that PELD combined with PRP hydrogel injection to treat patients with LDH is a safe and promising method. PRP injection was beneficial for disc remodelling after PELD.

Pathological complete response rate and clinical outcome after neoadjuvant therapy of HER2-low breast cancer: A National Cancer Database Analysis.

BACKGROUND: The interest in breast cancer with low HER2 expression as a distinct subtype is increasing. We aimed to explore the differences between HER2-low and HER2-zero breast cancer in their prognosis and rate of pathological complete response (pCR) after neoadjuvant therapy. METHODS: The National Cancer Database (NCDB) was used to select patients with breast cancer who received neoadjuvant therapy from 2004 to 2017. Logistic regression model was constructed for analysis of pCR. Cox proportional hazards regression model and Kaplan-Meier method were used for survival analysis. RESULTS: A total of 41500 breast cancer patients were included, among which 14814 (35.7%) had HER2-zero tumors and 26686 (64.3%) had HER2-low. HER2-low tumors were more commonly HR-positive in comparison with HER2-zero (66.3% versus 47.1%, P < 0.001). A lower rate of pCR was observed in HER2-low tumors than in HER2-zero tumors after neoadjuvant therapy in the total cohort (OR = 0.90; 95% CI [0.86-0.95]; P < 0.001) and in the subset of HR-positive (OR = 0.87; 95% CI [0.81-0.94]; P < 0.001). Patients with HER2-low tumors had a significantly superior survival than those with HER2-zero tumors (HR = 0.90; 95% CI [0.86-0.94]; P < 0.001), regardless of the HR status. Additionally, a marginal survival difference was also observed between HER2 IHC1+ and HER2 IHC2+/ISH-negative (HR = 0.91; 95% CI [0.85-0.97]; P = 0.003) cohorts. CONCLUSION: HER2-low tumors are a clinically relevant breast cancer subtype that is distinct from HER2-zero tumors. These findings may provide clues to appropriate therapeutic strategies for this subtype in the future.

Robot-assisted nipple-sparing mastectomy and immediate breast reconstruction with gel implant and latissimus dorsi muscle flap: Our initial experience.

BACKGROUND: This study reports the preliminary results of da Vinci robot XI robot-assisted nipple-sparing mastectomy immediate breast reconstruction (R-NSMIBR) with gel implant and latissimus dorsi muscle flap. METHODS: A total of 15 patients who underwent R-NSMIBR with gel implant and latissimus dorsi muscle flap surgery for breast cancer between September 2022 and November 2022 were evaluated. RESULTS: Mean total operative time for R-NSMIBR was 361.9 ± 77.0 min. As the learning curve increased, the robot arm docking time decreased rapidly from the initial 25-10 min. Average total blood loss was 27.8 ± 10.7 mL and posterior surgical margin positivity rate was 0%. Perioperative complications and local recurrences or deaths were not observed at a mean follow-up of 3 ± 1 month 15 patients were satisfied with postoperative aesthetic results. CONCLUSIONS: R-NSMIBR with a gel implant and latissimus dorsi muscle flap could be a new therapeutic option for breast reconstruction.

[Effectiveness of lobulated pedicled rectus abdominis myocutaneous flap for repairing huge chest wall defect].

Objective: To explore the effectiveness of lobulated pedicled rectus abdominis myocutaneous flap to repair huge chest wall defect. Methods: Between June 2021 and June 2022, 14 patients with huge chest wall defects were treated with radical resection of the lesion and lobulated pedicled rectus abdominis myocutaneous flap transplantation for reconstruction of chest wall defects. The patients included 5 males and 9 females with an average age of 44.2 years (range, 32-57 years). The size of skin and soft tissue defect ranged from 20 cm×16 cm to 22 cm×22 cm. The bilateral pedicled rectus abdominis myocutaneous flaps in size of 26 cm×8 cm to 35 cm×14 cm were prepaired and cut into two skin paddles with basically equal area according to the actual defect size of the chest wall. After the lobulated pedicled rectus abdominis myocutaneous flap was transferred to the defect, there were two reshaping methods. The first method was that the skin paddle at the lower position and opposite side was unchanged, and the skin paddle at the effected side was rotated by 90° (7 cases). The second method was that the two skin paddles were rotated 90° respectively (7 cases). The donor site was sutured directly. Results: All 14 flaps survived successfully and the wound healed by first intention. The incisions at donor site healed by first intention. All patients were followed up 6-12 months (mean, 8.7 months). The appearance and texture of the flaps were satisfactory. Only linear scar was left at the donor site, and the appearance and activity of the abdominal wall were not affected. No local recurrence was found in all tumor patients, and distant metastasis occurred in 2 breast cancer patients (1 liver metastasis and 1 lung metastasis). Conclusion: The lobulated pedicled rectus abdominis myocutaneous flap in repair of huge chest wall defect can ensure the safety of blood supply of the flap to the greatest extent, ensure the effective and full use of the flap tissue, and reduce postoperative complications.

[Technique and clinical application of free lobed anteromedial thigh perforator flap].

Objective: To introduce the technique and clinical application of free lobed anteromedial thigh perforator flap. Methods: Between October 2017 and December 2021, 65 patients with buccal and oral cancer penetrating defects were planned to treat with free lobed anterolateral thigh flap transplantation, of which 15 cases were found that the sole anterolateral thigh perforator was actually a branch of the anteromedial thigh perforator, and then the free lobed anteromedial thigh perforator flap was harvested for repair. There were 12 males and 3 females with an average age of 34.6 years (range, 29-55 years). According to Union for International Cancer Control (UICC) TNM staging, there were 7 cases of T 4N 0M 0, 4 cases of T 4N 1M 0, 2 cases of T 3N 1M 0, and 2 cases of T 3N 2M 0. The disease duration was 1-10 months (mean, 6.3 months), and the area of secondary soft tissue defect left after radical resection of buccal and oral cancer was from 5 cm×4 cm to 10 cm×6 cm. The anterolateral thigh skin flap ranged from 5 cm×4 cm to 13 cm×6 cm, and the anteromedial thigh skin flap ranged from 5 cm×3 cm to 10 cm×6 cm. The free trilobed anteromedial thigh flap was prepared according to the actual branches of the main trunk of the anteromedial thigh perforator in 4 cases, and the vastus medialis muscle flap was used to fill the cavity defect of the floor of mouth in 7 cases. Among the 15 patients, the vessel pedicles of the anteromedial thigh perforators were derived from the main femoral artery and vein in 8 cases, from the main descending branch of the lateral femoral circumflex artery in 4 cases, and from the main lateral femoral circumflex artery in 3 cases. Results: Hematoma occurred in 2 cases after operation, which was successfully saved after emergency exploration. No vascular crisis occurred, and partial necrosis of anterolateral femoral skin island occurred in 1 case, which was healed with debridement. The remaining flaps survived successfully, and the wounds and donor site incisions healed by first intention. All the patients were followed up 12-36 months (mean, 14.6 months). The appearance of the flap was satisfactory, and no obvious swelling was found; the mouth opening and language function were satisfactory; only linear scar was left in the donor area, and the thigh function was not significantly affected. Local recurrence occurred in 3 cases, and the defect after tumor resection was repaired with pedicled pectoralis major myocutaneous flap. Four patients with neck lymph node metastasis, including ipsilateral side in 3 patients and contralateral side in the other 1 patient, all underwent neck lymph node dissection again. The 3-year survival rate was 86.7% (13/15). Conclusion: The anteromedial thigh perforator vessels distributed in the anterolateral region of the thigh can be used to prepare the anterolateral thigh split lobed flap to repair the buccal and oral cancer penetrating defects.

[Combination mode and optimization strategy of harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap].

Objective: To summarize the combination methods and optimization strategies of the harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap. Methods: A clinical data of 359 cases of oral cancer admitted between June 2015 and December 2021 was retrospectively analyzed. There were 338 males and 21 females with an average age of 35.7 years (range, 28-59 years). There were 161 cases of tongue cancer, 132 cases of gingival cancer, and 66 cases of buccal and oral cancer. According to the Union International Center of Cancer (UICC) TNM staging, there were 137 cases of T 4N 0M 0, 166 cases of T 4N 1M 0, 43 cases of T 3N 1M 0, 13 cases of T 3N 2M 0. The disease duration was 1-12 months (mean, 6.3 months). The soft tissue defects in size of 5.0 cm×4.0 cm to 10.0 cm×7.5 cm remained after radical resection were repaired with the free anterolateral thigh chimeric perforator myocutaneous flaps. The process of harvesting the myocutaneous flap was mainly divided into 4 steps. Step 1: exposing and separating the perforator vessels, which mainly came from the oblique branch and the lateral branch of the descending branch. Step 2: isolating the main trunk of the perforator vessel pedicle and determining the origin of the vascular pedicle of muscle flap, which was came from oblique branch, lateral branch of the descending branch, or medial branch of the descending branch. Step 3: determining the source of muscle flap, including lateral thigh muscle and rectus femoris muscle. Step 4: determining the harvest form of muscle flap, which included muscle branch type, main trunk distal type, and main trunk lateral type. Results: The 359 free anterolateral thigh chimeric perforator myocutaneous flaps were harvested. In all cases, the anterolateral femoral perforator vessels existed. The perforator vascular pedicle of the flap came from the oblique branch in 127 cases and the lateral branch of the descending branch in 232 cases. The vascular pedicle of muscle flap originated from the oblique branch in 94 cases, the lateral branch of the descending branch in 187 cases, and the medial branch of the descending branch in 78 cases. The muscle flaps harvested from the lateral thigh muscle in 308 cases and the rectus femoris muscle in 51 cases. The harvest forms of muscle flaps included 154 cases of muscle branch type, 78 cases of main trunk distal type, and 127 cases of main trunk lateral type. The size of skin flaps ranged from 6.0 cm×4.0 cm to 16.0 cm×8.0 cm, and the size of muscle flaps range from 5.0 cm×4.0 cm to 9.0 cm×6.0 cm. In 316 cases, the perforating artery anastomosed with the superior thyroid artery, and the accompanying vein anastomosed with the superior thyroid vein. In 43 cases, the perforating artery anastomosed with the facial artery, and the accompanying vein anastomosed with the facial vein. After operation, the hematoma occurred in 6 cases and vascular crisis in 4 cases. Among them, 7 cases were successfully saved after emergency exploration, 1 case had partial necrosis of skin flap, which was healed after conservative dressing change, and 2 cases had complete necrosis of skin flap, which was repaired by pectoralis major myocutaneous flap. All patients were followed up 10-56 months (mean, 22.5 months). The appearance of the flap was satisfactory, and the swallowing and language functions were restored satisfactorily. Only linear scar left in the donor site with no significant effect on thigh function. During follow-up, 23 patients had local tumor recurrence and 16 patients had cervical lymph node metastasis. The 3-year survival rate was 38.2% (137/359). Conclusion: The flexible and clear classification of the key points in the harvest process of anterolateral thigh chimeric perforator myocutaneous flap can optimize the protocol to the greatest extent, increase the safety of the operation, and reduce the difficulty of the operation.

[Anatomical types and anastomosis methods of concomitant veins of deep inferior epigastric artery].

Objective: To summarize the anatomical types of the concomitant veins of deep inferior epigastric artery and the corresponding choice of anastomosis methods, and to evaluate the indications and safety of various methods. Methods: Between October 2015 and June 2021, 296 female patients received breast reconstruction with autologous free lower abdominal flap, including 154 cases of immediate breast reconstruction and 142 cases of delayed breast reconstruction. The average age of the patients was 36.5 years, ranged from 26 to 62 years. Unilateral free deep inferior epigastric artery perforator flap transplantation was performed in 172 cases, and unilateral free muscle-sparing rectus abdominis myocutaneous flap transplantation was performed in 124 cases. The internal thoracic vessels were selected as the recipient vessels in all cases. The length of vascular pedicle ranged from 9.5 to 13.0 cm, with an average of 11.2 cm. The concomitant veins of deep inferior epigastric artery included three anatomical types: one-branch type in 26 cases (8.8%), two-branch type in 180 cases (60.8%), and Y-shaped structure in 90 cases (30.4%). Anastomosis of inferior epigastric artery was performed with the proximal end of internal thoracic artery, while that of vein should be adjusted according to the diameter, length, wall thickness, and branches of the vein. The specific classification of venous anastomosis included: ① The sole concomitant vein of deep inferior epigastric artery was anastomosed with the internal mammary vein (26 cases); ② The two concomitant veins of deep inferior epigastric artery were anastomosed with the internal mammary vein respectively (151 cases); ③ The larger one of two concomitant veins of deep inferior epigastric artery was anastomosed with the internal mammary vein, and the other one was ligated and discarded (29 cases); ④ The two concomitant veins of deep inferior epigastric artery were Y-shaped, and the common trunk segment was directly anastomosed with the internal mammary vein (31 cases); ⑤ The smaller branch of the concomitant veins of Y-shaped structure was ligated, and the thicker branch was anastomosed with the internal mammary vein (17 cases); ⑥ The concomitant veins of Y-shaped structure were anastomosed with the internal mammary veins respectively (42 cases). Results: Among the patients who underwent venous anastomosis according to scheme ④, 3 cases had venous crisis of flap after operation, of which 1 case was successfully rescued by emergency exploration; the other 2 cases had flap necrosis, of which 1 case survived after being repaired by pedicled latissimus dorsi flap, and 1 case closed the wound directly. Flaps with other venous anastomosis protocols survived completely. All 296 patients were followed up 12-70 months, with an average of 37.5 months. The reconstructed breast has good shape, good elasticity, and no skin flap contracture. The donor site of the flap only left linear scar, and the abdominal wall function was not affected. Conclusion: The method of direct anastomosis of concomitant veins of deep inferior epigastric artery with Y-shaped structure is relatively risky, and the vessels are prone to be twisted and compressed, leading to the occurrence of venous crisis. It can improve the safety of surgery if only one large vein is anastomosed or two veins are separated to anastomose respectively.

The Role of Measurement of Pedicle Length for DIEP Flap Transferring in Breast Reconstruction: A Single-Center, Open-Label, Randomized Controlled Trial.

BACKGROUND: Intraoperative venous congestion is a main complication in deep inferior epigastric artery perforator (DIEP) flap for breast reconstruction. We present a pedicle measuring technique to precisely predict the length of pedicle needed in DIEP free flap, to improve the outcome, and to reduce the risk of donor site morbidity and complications. MATERIALS AND METHODS: A single-center, open-label, prospective, randomized study was carried out to access efficacy and safety of a pedicle measuring technique in 389 patients. Each patient received a delayed breast reconstruction using free unipedicled DIEP flap, and internal mammary vessels were chosen as recipient vessels. During the surgery, the conventional DIEP flap technique was used in the control group, in which the course of the pedicle was fully dissected. In the measuring group, the flap in setting way was decided preoperatively, the distance (A) between the internal mammary vessels (a) and the point of DIEP perforator into the subcutaneous tissue (b) was measured, and then the length (B) of the perforator (c) and the main trunk (d) is measured and dissected to achieve 1 cm longer than A. RESULTS: There are 180 and 209 patients enrolled in the control and measuring group, respectively. Venous congestion occurred in 15 patients (8.3%) in the control group, and 1 patient (0.5%) in the measuring group ( P < 0.001). All the 16 patients were found venous thrombosis. Then successful free flap salvage surgeries were performed in 10 patients. Six patients (3.3%) had total flap necrosis due to recurrent venous thromboembolisms. Fat necrosis occurred in 16 patients (8.9%) in the control group, and 5 patients (2.4%) in the measuring group ( P = 0.006). Partial flap necrosis was found in 12 patients (6.7%) in the control group, and in 3 patients (1.4%) in the measuring group ( P = 0.008). Total flap necrosis occurred in 6 patients (3.3%) in the control group, but no (0%) patient in the measuring group ( P = 0.009). CONCLUSIONS: Measurement of pedicle length for DIEP flap transferring in breast reconstruction is a reliable technique that could secure the DIEP free flap, reduce operative invasiveness, and lower the risk of complications considerably.

The "Domino Flaps" Concept: Functional Composite Reconstruction for Traumatic Transmetacarpal Thumb Amputation.

Complex transmetacarpal thumb amputation remains a challenging reconstructive injury. Optimal reconstructive options aim to achieve a neo-thumb with optimal length, sensitivity, stability, and an aesthetically functional result. In cases when immediate replantation of the amputated digit is not possible, a temporary ectopic replantation with staged reconstruction can be deployed. We report our experience of a complex transmetacarpal thumb amputation managed with a staged "domino flap" concept. The first stage involved an ectopic replantation of the amputated digit with a second stage replantation 3 weeks later. Domino flap refers to the requirement of a further reconstruction due to the defect at the donor sites. In this case, the replant is accompanied by 2 domino flap reconstructions with the dorsalis pedis composite free flap to reconstruct the first metatarsal and an anterior tibial artery propeller perforator flap to reconstruct the composite flap donor site.

Reconstruction of chronic radiation-induced ulcers in the chest wall using free and pedicle flaps.

Background and purpose: Resection of radiation-induced ulcers often causes full-thickness defects of the chest wall. We retrospectively reviewed and evaluated 17 patients to explore a method of chest wall reconstruction. Materials and methods: A total of 17 breast cancer patients with radiation-induced ulcers were included. Various type of prostheses and flaps were used, results of clinic were evaluated. Results: Sixteen patients had full-thickness defects and one patient had only a soft tissue defect and underwent reconstruction with a pedicle latissimus dorsi (LD) myocutaneous flap. Among all 16 full-thickness defect cases, 15 patients underwent bony thoracic reconstruction using polymesh/3D-printed titanium plates or methyl methacrylate. For soft tissue reconstruction, 13 patients reconstruction using a free deep inferior epigastric perforator (DIEP) flap in combination with a contralateral transverse rectus abdominis myocutaneous (TRAM) flap, and 2 underwent pure free DIEP flap reconstruction. Among all the patients 15 healed with no complications, and 2 patients had delayed healing on the edges of the flaps. Conclusions: Distant pedicle or free flap can used for soft tissue defect coverage, for those severe patients with full-thickness defects and used prostheses, free deep inferior epigastric perforator flap in combination with a contralateral transverse rectus abdominis myocutaneous flap (TRAM + DIEP) would be an applicable choice.

[Application of anterior serratus branch of thoracodorsal vessel in repairing chest wall defect].

Objective: To investigate the application of anterior serratus branch of thoracodorsal vessel in repairing chest wall defect. Methods: Between October 2018 and March 2021, bilateral free lower abdominal flaps were used to repair large-area complex defects after chest wall tumor surgery in 23 patients. The patients were all female; the age ranged from 23 to 71 years, with an average age of 48.5 years. There were 11 cases of locally advanced breast cancer, 4 cases of phyllodes cell sarcoma, 3 cases of soft tissue sarcoma, 3 cases of recurrence of breast cancer, and 2 case of osteoradionecrosis. The size of secondary chest wall defect after tumor resection and wound debridement ranged from 20 cm×10 cm to 38 cm×14 cm, the size of flap ranged from 25 cm×12 cm to 38 cm×15 cm, the length of vascular pedicle was 9-12 cm (mean, 11.4 cm). Fourteen cases of simple soft tissue defects were repaired by flap transplantation; 5 cases of rib defects (<3 ribs) and soft tissue defects were repaired by simple mesh combined with flap transplantation; and 4 cases of full-thickness chest wall defect with large-scale rib defect (>3 ribs) were repaired by "mesh plus bone cement" rigid internal fixation combined with flap transplantation. The anterior serratus branch of thoracodorsal vessel was selected as the recipient vessel in all cases, the revascularization methods include 3 types: the proximal end of the anterior serratus branch plus other recipient vessels (13 cases), proximal and distal ends of anterior serratus branch (6 cases), and proximal ends of two anterior serratus branches (4 cases). Results: The main trunk of thoracodorsal vessels was preserved completely in 23 patients. All patients were followed up 10-18 months, with an average of 13.9 months. After operation, the flap survived completely, the shape of reconstructed chest wall was good, the texture was satisfactory, and there was no flap contracture deformation. There was only a linear scar left in the flap donor site, and the abdominal wall function was not significantly affected. There was no tumor recurrence during follow-up. Conclusion: The anterior serratus branch of thoracodorsal vessel has a constant anatomy and causes little damage to the recipient site, so it can provide reliable blood supply for free flap transplantation.

[Application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect].

Objective: To investigate the application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect. Methods: Between August 2018 and December 2020, 12 patients, including 4 males and 8 females, were treated with expanded anterolateral thigh myocutaneous flap to repair huge complex defects after thoracic wall tumor surgery. The age ranged from 28 to 72 years, with an average of 54.9 years. There were 4 cases of phyllodes cell sarcoma, 2 cases of soft tissue sarcoma, 1 case of metastatic chest wall tumor of lung cancer, and 5 cases of breast cancer recurrence. All cases underwent 2-7 tumor resection operations, of which 3 cases had previously received lower abdominal flap transplantation and total flap failure occurred, the other 9 cases were thin and were not suitable to use the abdomen as the flap donor site. After thorough debridement, the area of secondary chest wall defect was 300-600 cm 2; the length of the flap was (24.7±0.7) cm, the width of the skin island was (10.6±0.7) cm, the length of the lateral femoral muscular flap was (26.8±0.5) cm, the width was (15.3±0.6) cm, and the length of the vascular pedicle was (7.9±0.6) cm. Results: The myocutaneous flaps and the skin grafts on the muscular flaps were all survived in 11 patients, and the wounds in the donor and recipient sites healed by first intention. One male patient had a dehiscence of the chest wall incision, which was further repaired by omentum combined with skin graft. The appearance of the reconstructed chest wall in 12 patients was good, the texture was satisfactory, and there was no skin flap contracture and deformation. Only linear scar was left in the donor site of the flap, and slight hyperplastic scar was left in the skin harvesting site, which had no significant effect on the function of the thigh. All patients were followed up 9-15 months, with an average of 12.6 months. No tumor recurrence was found. Conclusion: The expanded anterolateral thigh myocutaneous flap surgery is easy to operate, the effective repair area is significantly increased, and multiple flap transplantation is avoided. It can be used as a rescue means for the repair of huge chest wall defects.

Research on Mechanism of Nanometric Bone Pulp Activated with Double Gene as Bone Morphogenetic Protein 1 and Vascular Endothelial Growth Factor for Improving the Strength of Centrum in Osteoporosis.

The aim of this study was assessing the mechanism of nanometric bone pulp activated with double gene as bone morphogenetic protein 1 (BMP-1) and vascular endothelial growth factor (VEGF) in improving the strength of centrum in osteoporosis (OP). The model of nanometric bone pulp activated with BMP-1 and VEGF double gene was established and validated. Under maximum condition of load and collapsed fragments, the model was analyzed through biomechanical test. The conditions for ALP, BGP, MLL and BMD in the model were also analyzed, and three-dimensional structural transformation was analyzed. Western blot and qRT-PCR were used to detect the effect of adding or not adding dual gene activated nano-bone stickers on OC-specific protein and mRNA; ELISA kits were used to detect the changes of RANKL pathway RANKL, OPG and TRACP5b. The maximum conformed quality and condensed intensity were strengthened with the nanometric bone pulp activated with BMP-1 and VEGF double gene. The maximum load in centrum was extremely elevated in the model, and the condition of ALP and its effect on bone was partly improved in the model. The precision and efficiency in the quality of BMD were continuously decreased. The BMD and MLF were strengthened notably in the model, and their effect on the bone was extremely improved. There was tight displayed model of trabecular in centrum and porosity was also continuously reduced. After adding the double-gene activated nano-bone stickers, the results from qRTPCR and Western blot showed that the changes of osteoclast-related genes and protein expressions were significantly down-regulated. The nanometric bone pulp activated with BMP-1 and VEGF double gene was one of ideal filled criterion. The BMD and bone strength were also elevated.

[Role of intercostal neurovascular perforator in lower abdominal flap].

Objective: To investigate if intercostal neurovascular perforator can nourish lower abdominal flap. Methods: Between June 2017 and December 2020, in 39 female patients with predominant perforator originated from intercostal nerve nutrient vessels, main trunk of the deep inferior epigastric vessels was chosen to be the pedicle to harvest free lower abdominal flap for breast reconstruction. The age of the patients ranged from 28 to 52 years, with an average of 38.6 years. There were 16 cases on the left and 23 cases on the right. The duration of breast cancer was 3-32 months, with an average of 21.8 months. Pathological stage was stageⅡin 31 cases and stage Ⅲ in 8 cases. Among them, 25 cases were primary tumor resection and one stage breast reconstruction and 14 cases were delayed breast reconstruction. Results: The lower abdominal flap pedicled with one side pedicle was harvested in 32 cases, all of which were supplied by the main trunk of the deep inferior epigastric vessel combined with the intercostal neurovascular perforator; 7 cases were harvested with bilateral pedicled lower abdominal flaps, of which 4 cases were supplied by the main trunk of the deep inferior epigastric vessel combined with intercostal neurovascular perforator on one side and deep inferior epigastric artery perforator on the other side, and the other 3 cases were supplied by bilateral main trunk of the deep inferior epigastric vessel and the intercostal neurovascular perforator. In the flaps nourished with the main trunk of the deep inferior epigastric vessel combined with the intercostal neurovascular perforator, the intercostal neurovascular perforators were one branch type in 15 cases, one branch+reticular type in 19 sides, and reticular type in 8 sides. The size of flap ranged from 26 cm×10 cm to 31 cm×13 cm; the thickness was 2.5-5.5 cm (mean, 2.9 cm); the vascular pedicle length was 7.0-11.5 cm (mean, 9.2 cm); the weight of the flap was 350-420 g (mean, 390 g). All the flaps survived completely and the incisions at donor sites healed by first intention. All patients were followed up 14-35 months (mean, 25.4 months). The shape, texture, and elasticity of reconstructed breasts were good and no flap contracture happened. Only linear scar left at the donor site, the function of abdomen was not affected. No local recurrence happened. Conclusion: When the direct perforator of the deep inferior epigastric artery may not provide reliable blood supply for the lower abdominal flap, the intercostal neurovascular perforator with deep inferior epigastric vessels can ensure the blood supply of the free lower abdominal flap.

Patient Management Strategies in Perioperative, Intraoperative, and Postoperative Period in Breast Reconstruction With DIEP-Flap: Clinical Recommendations.

BACKGROUND AND OBJECTIVE: Deep Inferior Epigastric Perforator (DIEP) flap is a tissue isolated from the skin and subcutaneous tissue of the lower abdomen or rectus muscle to foster breast reconstruction. There is limited information about DIEP-flap induced complications associated with breast reconstruction surgery. EVIDENCE: We conducted a systematic review of the published literature in the field of breast cancer reconstruction surgery. Information was gathered through internet resources such as PubMed, Medline, eMedicine, NLM, and ReleMed etc. The following key phrases were used for effective literature collection: "DIEP flap", "Breast reconstruction", "Patient management", "Postoperative DIEP", "Intraoperative anticoagulant therapy", "Clinical recommendations". A total of 106 research papers were retrieved pertaining to this systematic review. CONCLUSION: A successful breast reconstruction with DIEP-flap without complications is the priority achievement for this surgical procedure. This study provides various evidence-based recommendations on patient management in the perioperative, intraoperative, and postoperative periods. The clinical recommendations provided in this review can benefit surgeons to execute breast reconstruction surgery with minimal postoperative complications. These recommendations are beneficial to improve clinical outcomes when performing surgery by minimizing complications in perioperative, intraoperative, and postoperative period.

Multi-pedicled long fasciocutaneous free flaps in complex lower extremity reconstruction.

Fasciocutaneous free tissue transfer is an established limb salvage modality in lower extremity reconstruction. In severe cases, defect coverage is challenging due to the size and extent of the injury which may surpass the dimensions of most commonly utilized fasciocutaneous donor sites. This is further complicated by the considerable length between the recipient pedicle and most distal segment of the defect requiring coverage. Available donor sites that are able to provide free fasciocutaneous flaps extended length (>40 cm) are combinations between the lateral thoracic, lower abdomen/groin and lateral thigh regions. Advantages of this include a single donor site that can be closed primarily, the ability to utilize healthy vessels outside the zone of trauma/injury for microvascular anastomosis and single stage reconstruction. In addition, from a logistical perspective, single flap harvest would theoretically be more efficient and less resource intensive than harvesting two separate flaps or performing large skin grafts. Herein, we present current available donor sites that allow harvest of long fasciocutaneous free flaps incorporating multiple pedicles with a single skin paddle for lower extremity reconstruction.

NAP1L1 interacts with hepatoma-derived growth factor to recruit c-Jun inducing breast cancer growth.

BACKGROUND: Breast cancer is a common cancer among women in the world. However, its pathogenesis is still to be determined. The role and molecular mechanism of Nucleosome Assembly Protein 1 Like 1 (NAP1L1) in breast cancer have not been reported. Elucidation of molecular mechanism might provide a novel therapeutic target for breast cancer treatment. METHODS: A bioinformatics analysis was conducted to determine the differential expression of NAP1L1 in breast cancer and find the potential biomarker that interacts with NAP1L1 and hepatoma-derived growth factor (HDGF). The expression of NAP1L1 in tissues was detected by using immunohistochemistry. Breast cancer cells were transfected with the corresponding lentiviral particles and siRNA. The efficiency of transfection was measured by RT-qPCR and western blotting. Then, MTT, Edu, plate clone formation, and subcutaneous tumorigenesis in nude mice were used to detect the cell proliferation in breast cancer. Furthermore, coimmunoprecipitation (Co-IP) assay and confocal microscopy were performed to explore the detailed molecular mechanism of NAP1L1 in breast cancer. RESULTS: In this study, NAP1L1 protein was upregulated based on the Clinical Proteomic Tumor Analysis Consortium (CPTAC) database. Consistent with the prediction, immunohistochemistry staining showed that NAP1L1 protein expression was significantly increased in breast cancer tissues. Its elevated expression was an unfavorable factor for breast cancer clinical progression and poor prognosis. Stably or transiently knocking down NAP1L1 reduced the cell growth in vivo and in vitro via repressing the cell cycle signal in breast cancer. Furthermore, the molecular basis of NAP1L1-induced cell cycle signal was further studied. NAP1L1 interacted with the HDGF, an oncogenic factor for tumors, and the latter subsequently recruited the key oncogenic transcription factor c-Jun, which finally induced the expression of cell cycle promoter Cyclin D1(CCND1) and thus the cell growth of breast cancer. CONCLUSIONS: Our data demonstrated that NAP1L1 functions as a potential oncogene via interacting with HDGF to recruit c-Jun in breast cancer.

[Effect of free deep inferior epigastric artery perforator flap transplantation in breast shaping of two-staged breast reconstruction with vertical scar].

OBJECTIVE: To summarize the difficulties and key points of free deep inferior epigastric artery perforator flap (DIEP) transplantation in breast shaping of two-staged breast reconstruction with vertical scar. METHODS: The clinical data of 32 postoperative breast cancer patients after mastectomy who underwent free DIEP transplantation for breast reconstruction between October 2015 and October 2019, whose original surgical incisions were all vertical and longitudinal, were retrospectively analysed. All the patients were female, aged from 31 to 42 years, with an average of 34.6 years. The disease duration of breast cancer ranged from 9 to 48 months (mean, 22.8 months). Free DIEP pedicled with contralateral vessels were used in all cases, and the recipient vessels were intrathoracic vessels. Among them, 17 flaps were placed longitudinally, 15 flaps were placed obliquely; Z-shaped flaps were used in 18 cases to adjust the chest wall skin contracture, and contralateral breast reduction and mastopexy were accomplished at the same time in 23 cases. RESULTS: All DIEP survived completely, and all donor and recipient sites healed by first intention. Internal thoracic lymph node metastasis was found in 1 case and treated with radiotherapy. All 32 cases were followed up 9-48 months, with an average of 19.4 months. The appearance and texture of all flaps were satisfactory, and only linear scar was left in donor site. Eleven patients underwent further autologous fat transplantation and nipple reconstruction. All patients had no effect on abdominal wall activity, and no local recurrence and metastasis was found. CONCLUSION: It is difficult to use free DIEP for two-staged breast reconstruction in patients received mastectomy with vertical longitudinal scar left. Combined with different breast shaping techniques, the outcomes can significantly improve.