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The pedicled lower trapezius musculocutaneous flap (LTMF) can extend far beyond the lateral border of the trapezius muscle, with a reliable blood supply. However, the distal part of the extended LTMF lacks a muscular component, limiting its usage in complex defect reconstruction, which often requires obliteration of dead space and coverage of vital structures. To overcome this limitation, we modified the LTMF by adding a segment of latissimus dorsi muscle (LDM). Between 2014 and 2021, the modified extended LTMF was used to reconstruct complex defects in the head, neck, shoulder, and contralateral chest wall and back in 19 patients. By preserving the interconnections between the branches of the posterior intercostal arteries, we were able to include various amounts of LDM within the extended LTMF. The LDM component was used to obliterate dead space and repair wounds involving cerebrospinal fluid leakage, infection, radioactive osteomyelitis, exposed carotid artery, lung, and implant materials. The average flap size was 30.7 cm × 10.9 cm (range: 25 × 8 cm-40 × 14 cm). The average size of the LDM was 113.9 cm

Sideburns are crucial for head and face esthetics. Absence of sideburns is associated with physical and psychological consequences. Many methods have been described for sideburn reconstruction; however, characteristics of the ideal method include optimal vascularization, ideal hair density, natural hair growth, and facial symmetry with minimum donor-site morbidity. In this study, the authors describe a novel method of sideburn reconstruction using a pre-expanded island scalp flap based on the parietal branch of the superficial temporal artery. Between February 2012 and December 2020, 9 patients underwent sideburn reconstruction surgery that involved 2 stages. During the first stage, an appropriately sized tissue expander was inserted underneath the scalp. After sufficient inflation of the expander, at the second stage, an island scalp flap based on the parietal branch of the superficial temporal vessels was elevated to reconstruct the sideburns. The mean size of the defects was 8 × 4.4 cm (range, 6 × 3-12 × 5 cm), whereas the average flap dimension was 10.22 × 5.67 cm (range, 8 × 4-13 × 8 cm). All flaps survived completely without any perfusion-related complications. Patients were followed up after surgery, ranging from 4 to 34 months (mean, 15.67 months). All patients and/or their parents were satisfied with the final appearance in terms of hair density, hair growth direction, and facial symmetry. Although a 2-stage procedure, this novel technique allows the reconstruction of a new sideburn with natural growth and orientation of the hair and minimal morbidity for patients.

The pedicled lower trapezius myocutaneous flap is generally transferred to the recipient site through a subcutaneous tunnel, and a portion of the flap buried in the tunnel needs to be de-epithelialized. Thus, considerable amount of normal skin is sacrificed, and the redundant tissue buried in the tunnel can cause bulging deformity. We believe that transferring the lower trapezius myocutaneous flap in a propeller fashion can avoid the aforementioned issues.A retrospective review was performed on all lower trapezius myocutaneous propeller flap reconstructions by a single surgeon from July 2013 to March 2021. Data on patient demographics, diagnosis, features of the defect, characteristics of the flap, and the outcome were collected and analyzed.Thirty-three lower trapezius myocutaneous propeller flaps were used to reconstruct soft tissue defects in the head, neck, and back. The etiologies were malignancy, trauma, postburn scar contracture, and congenital melanocytic nevus. The mean skin paddle dimensions were 29.0 cm in length (range, 13-45 cm) and 10.9 cm in width (range, 6-15 cm). The donor sites were closed primarily in 30 patients, closed using a skin graft in 1 patient, and covered with the second flap in 2 patients. Venous congestion occurred in the distal portion of 4 flaps and partial necrosis in the distal 6 cm of 1 flap. The average follow-up time was 17.5 months (range, 1-56 months). The normal contour of the back was preserved without bulging deformity. No patient developed a winged scapula or a decrease in shoulder elevation.The lower trapezius myocutaneous propeller flap may be an option for reconstruction of soft tissue defects of the head, neck, and back with less waste of normal tissue and bulging deformity.

Background Designing a skin flap that perfectly covers the anatomical and dynamic territories is challenging. Tissues capturing territories beyond may be insufficiently perfused, and these hypoperfused areas can lead to partial flap necrosis. Indocyanine green angiography (ICGA) is an effective tool for identifying hypoperfused areas. This retrospective study proposes a standardized strategy for managing the hypoperfused areas identified by ICGA in pre-expanded extended lower trapezius myocutaneous (e-LTMC) flaps. Methods Patients who underwent pre-expanded e-LTMC flap surgery with perfusion assessment using ICGA between June 2016 and January 2022 were identified. A standardized protocol was applied, and patients were divided into four groups according to different management options for hypoperfused areas detected by ICGA. Preoperative and operative variables of interest and postoperative outcomes, including flap necrosis and flap survival length, were collected and analyzed. Results Sixty-nine flaps were included in the study. No total flap necrosis was observed. Partial necrosis occurred in 10 flaps. Significant differences were observed in the incidence of full-thickness necrosis between the management groups. The incidence of flap necrosis in cases where management relied on ICGA findings was significantly lower than that of cases where management did not rely on ICGA findings. There were no differences in the relative survival length of the flap between cases with and without intervention for the hypoperfused areas. Conclusion The proposed standard strategy effectively reduced the necrosis rate of the pre-expanded e-LTMC flap, thus it is sensible to act on the ICGA findings. Prophylactic resection of the hypoperfused area should be recommended. Where resection may lead to poor reconstructive outcomes, flap trimming or a second flap should be the preferred option.

The pre-expanded medial arm flap provides suitable skin for the resurfacing of a periorbital or perioral defect. However, the flap must be intraoperatively split to imitate the appearance of the oral or ophthalmic fissure, which can compromise flap perfusion. This study aimed to evaluate the safety and effectiveness of splitting pre-expanded medial arm flaps with the aid of indocyanine green angiography. All 8 patients underwent periorbital or perioral soft tissue reconstruction using a split pre-expanded medial arm flap. Flap splitting was aided by indocyanine green angiography. It was used during 2 stages of the procedure, tissue expander placement and flap transfer. The pedicle was divided 3 weeks later, and the flaps were used to resurface the defect. The distal portion of the flap was split into a fishmouth pattern in 5 patients and a window pattern in 3 patients. The donor sites were closed directly or by using a latissimus dorsi myocutaneous flap. There were no perioperative complications or flap necrosis. A pre-expanded split medial arm flap could be an option for the reconstruction of periorbital and perioral defects. With the assistance of indocyanine green angiography, vessel distribution and distal flap perfusion can be reliably evaluated, facilitating the safe splitting of the flap for the reconstruction of defects.

Aims Tendon development requires the coordinated interaction of muscles and tendons. Muscle-derived cells (MDCs), a mixed cell population containing both myogenic and fibroblastic cell subsets, have been found to be ideal seed cells for tendon regeneration. However, the necessity of these cell types for tendon regeneration has not yet been tested. In this study, we aim to explore the possible synergistic effects of myogenic cells and fibroblasts in engineered tendon regeneration. Methods MDCs were separated into rapidly adhering cell (RAC; fibroblasts) and slowly adhering cell (SAC; myogenic cells) populations. Myogenic- and tenogenic-related molecules were analyzed by immunofluorescent staining, RT-PCR and real-time PCR. The proliferative abilities of MDCs, RACs and SACs were also evaluated. Cell-scaffold constructs were implanted into nude mice, and subsequently evaluated for their histologic, ultrastructure, gene expression, and biomechanical characteristics. Results MDCs have better proliferative activity than RAC and SAC population. RACs could express higher levels of tenogenic-related molecules tenomodulin (TNMD) and scleraxis (SCX) than SACs. Whereas SACs only expressed myogenic-related molecules MyoD. In contrast to the tendons engineered using RACs and SACs, the tendons engineered using MDCs exhibited a relatively more mature and well-organized tissue structure and ultrastructure as well as better mechanical properties. Conclusions Fibroblasts in muscle may be the primary cell population involved in tendon regeneration and that myogenic cells are an important component of the niche and control the fibroblast activity during tendon regeneration. The synergistic effects between fibroblasts and myogenic cells significantly contribute to efficient and effective regeneration of engineered tendons.

En bloc reconstruction of extensive head and neck defects is feasible with matched tissue from the medial arm or chest. Nevertheless, the donor site faces significant morbidity following massive cutaneous flap harvesting. The serial flap transfer technique can increase the reconstructive ability of these flaps and minimize the donor site morbidity. A retrospective review was conducted from 2016 to 2020 on all patients who had undergone extensive head and neck reconstruction with the serial flap transfer technique. En bloc reconstruction of defects in the head and neck was performed using expanded perforator-plus flaps from the medial arm or chest; various flaps from the back were used to close the donor-site defects. Flap type, flap survival, complications, and revision procedures were assessed. This case series included 16 patients. The donor site of the chest or medial arm was successfully closed with the assistance of the thoracodorsal artery perforator flap, the latissimus dorsi myocutaneous flap, ortheparascapular flap. A medial arm flap with a width of 15 cm and a chest flap with a 16 cm width could be transferred with the primary closure of the donor sites. All flaps survived, except 1 had marginal necrosis. Complications occurred in 2 patients and were successfully managed nonsurgically. Both the recipient and donor sites were restored with good aesthetic results. Application of the serial flap transfer technique in extensive head and neck reconstruction decreases the donor site morbidity to a minimum and improves the overall outcomes.

The preoperative identification of perforators is critical to the success of perforator flaps. Several technologies, including handheld Doppler (HHD) and indocyanine green angiography (ICGA), facilitate this process; however, each technology comes with unique downsides. This study directly compares the performance of HHD and ICGA in preoperative perforator identification and measures the effects of flap thickness and body mass index (BMI) on perforator localization.Data from preoperative HHD and ICGA assessments were compared with the criterion standard of intraoperative perforator localization. Sensitivity, specificity, accuracy, and positive predictive values were calculated for both and correlated with flap thickness and BMI.Thirty flaps were transferred in 30 patients across 15 different donor sites. Indocyanine green angiography had higher sensitivity, accuracy, and positive predictive value (79.2%, 74.2%, and 87.5%, respectively) than HHD (55.6%, 46.6%, and 69.4%, respectively). Perforators detected by ICGA were used as flap pedicles in 21 cases compared with 13 with HHD. There were no correlations between HHD or ICGA performance and patient BMI (both P0.05). Increasing flap thickness was negatively correlated with the accuracy of ICGA ( P = 0.001) but not HHD ( P0.05).Indocyanine green angiography was more sensitive, specific, and accurate than HHD in identifying perforators across various donor sites; however, its performance suffered in thicker flaps, whereas HHD did not. Patient BMI was not correlated with the performance of either technology. Additional research can further delineate the interrelationships of flap thickness and technologies for perforator localization.

SUMMARY The medial arm flap has multiple advantages when used for cervicofacial defect reconstruction but remains underused. The main drawback of the medial arm flap is that the patient must maintain the passive immobilized posture before the pedicle division. This clinical study aims to introduce a reconstructive method for cervicofacial defects using the medial arm flap without the immobilization of the upper extremity. This retrospective study was performed with data from 14 patients requiring pre-expanded medial arm flaps to reconstruct cervicofacial defects. Indocyanine green (ICG) angiography was used to detect perforators and evaluate the flap perfusion; all the flaps underwent pre-transfer tissue expansion. A total of 15 full-length medial arm flaps were used. All the perforators identified by ICG angiography were directly visualized during flap elevation. In four cases, poor perfusion areas in the flaps were noted by intraoperative ICG angiography. Combined with the clinical observation, parts with poor perfusion were resected. The average flap size was 203.9 ± 75.2 cm2 and ranged 20 to 28 cm in length after tissue expansion. The medial arm donor sites were closed directly or using another flap. All flaps survived completely. The patients were followed-up for 1 to 22 months. All patients and their family members were satisfied with the outcomes. Cervicofacial defect reconstruction using a medial arm flap with the aid of tissue expansion and ICG angiography can provide sufficient tissue for defect resurfacing and also eliminate the necessity of the immobilization of the upper extremity during surgery.

BACKGROUND Clinical examination alone is neither sensitive nor specific for predicting flap necrosis, so several technologies, including indocyanine green angiography, thermal imaging (using the FLIR ONE), and near-infrared spectroscopy, have been developed to supplement perfusion assessment. This study aims to compare the accuracy of these three methods for intraoperatively predicting clinical flap necrosis in a rat perforator flap model. The authors hypothesized that near-infrared spectroscopy, assessing oxygenation rather than direct perfusion, would yield significantly different predictions. METHODS A 10 × 3-cm epigastric perforator flap was elevated in 14 adult male rats weighing 250 ± 50 g. Flap perfusion was assessed immediately after flap elevation using thermal imaging, near-infrared spectroscopy, and indocyanine green angiography. Measurements were correlated to the clinical endpoint and gold standard of flap necrosis on postoperative day 7. RESULTS All three technologies detected significant differences in perfusion along flap length (all p < 0.001), and were associated with significant differences in the odds of developing flap necrosis (all p < 0.001). The areas under the receiver operating characteristic curves were 0.948 for indocyanine green angiography as an absolute value, 0.873 for relative changes with thermal imaging, and 0.792 for tissue oxygenation. The sensitivity, specificity, and accuracy for indocyanine green angiography measured as an absolute value were the highest at 97.8, 87.5, and 92 percent, respectively. CONCLUSIONS Indocyanine green angiography most accurately predicted flap necrosis in this study; however, tissue oximetry and thermal imaging were also capable of predicting necrosis and represented potentially less expensive or more readily available alternatives for objective perfusion assessment. Additional research can further delineate their roles and cost-efficacy in clinical practice.

The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm2 in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.

Background Although propeller flaps are a useful option for soft tissue defect reconstruction, reports based on the perforators of the lateral circumflex femoral artery (LCFA) are rare. We aimed to present our experience in defect reconstruction using the propeller flaps based on perforators from different branches of LCFA and apply these flaps in soft tissue defect reconstruction of the lower extremities. Methods Twenty nine patients (32 flaps) underwent defect reconstruction using propeller flaps based on the perforator of the LCFA. Defects were located from the groin to the proximal leg. According to the source vessels from which the perforator originated, flaps were categorized into types I, II, III and IV, which represented perforators from the transverse, descending, oblique, and rectus femoris branches, respectively. Type II flaps were subdivided into types IIa and IIb flaps based on antegrade and reverse flows of the descending branch. Results Flap sizes ranged from 12 × 6 cm to 30 × 15 cm (average, 22.69 × 9.19 cm) with the length of the vascular pedicle ranging from 3 to 7 cm (average, 4.86 cm). Flaps were rotated from 60° to 180° (average, 144.06°). There were 3 type I, 10 type IIa, 4 type IIb, 13 type III and, and 2 type IV flaps. Twenty-nine flaps survived after surgery. Total flap necrosis and venous congestion of the distal flap portion occurred in 1 and 2 patients, respectively. Conclusions Reconstruction using propeller flaps based on perforators of the LCFA is a safe, reliable, and versatile option for defect reconstruction of the lower extremities; however, it requires meticulous surgical dissection and patience.

The tissues of the medial arm as a donor site for perforator flap design have several advantages. However, they are relatively underused with limited reports, partly due to unreliable perforator anatomy. Therefore, we aimed to review our preliminary experience using indocyanine green (ICG) angiography to design and elevate preexpanded pedicled brachial artery perforator (BAP) flaps for regional reconstruction. All patients underwent soft tissue reconstructions using a preexpanded BAP flap in two or three stages. ICG angiography was used to localize perforators during both expander insertion and flap elevation. The pedicle was divided at the third stage 3 weeks following flap elevation for head and neck cases. Sixteen patients underwent reconstructions of the head and neck (n = 13) or shoulder/trunk (n = 3) using 14 perforator-plus and 2 propeller BAP flaps. In total, 50 perforators were identified using ICG imaging, all of which were appreciable during both expander placement and flap elevation. Thirty-five perforators were directly visualized during flap elevation, and an additional 15 perforators were not explored but incorporated into the flap. All flaps survived without necrosis, and the donor sites healed uneventfully without complications. The medial arm provides thin and pliable skin for the resurfacing of regional defects with relatively minimal donor-site morbidity. With the assistance of ICG angiography, perforators of the brachial artery can be reliably identified, facilitating the preexpansion and elevation of pedicled BAP flaps for use in head–neck and trunk reconstruction.

To explore the feasibility and effectiveness of perforator propeller flap sequential transfer technique in repair of soft tissue defect of distal lower extremity.Between July 2015 and July 2021, 10 patients with soft tissue defect of distal lower extremity were treated with perforator propeller flap sequential transfer technique. There were 8 males and 2 females, with a median age of 47 years (range, 6-71 years). The etiologies included malignant tumor in 5 cases, trauma in 3 cases, postburn scar contracture in 1 case, and diabetic foot ulcer in 1 case. The defects were located at the pretibial area in 1 case, the distal lower extremity and Achilles tendon in 3 cases, the dorsum of foot and lateral malleolar area in 4 cases, the heel in 1 case, and the plantar foot in 1 case. The size of the defect ranged from 5 cm×3 cm to 8 cm×8 cm. Peroneal artery perforator propellor flaps (the 1st flap) in size of 14 cm×4 cm to 29 cm×8 cm were used to repair the defects of distal lower extremity. The donor site defects were repaired with the other perforator propeller flaps (the 2nd flap) in size of 7 cm×3 cm to 19 cm×7 cm. The donor site of the 2nd flap was directly closed.All the operations were successfully completed and all of the 2nd flaps were elevated within 1 hour. Eight the 1st flaps survived completely; 2 had venous congestion. Among the 2 patients with venous congestion, 1 had necrosis of the distal end of the flap, and the secondary wound was repaired by skin grafting; 1 recovered spontaneously after 7 days. The 2nd flaps totally survived. No complication such as hematoma or infection occurred. Primary closure was achieved in all the recipient and donor sites. All patients were followed up 2-39 months，with a median of 15.5 months. The color, texture, and thickness of the flaps matched well with those of recipient sites. The normal contour of the leg was preserved. During follow-up, no recurrence of malignance or ulcer was observed. The scar contracture was completely released. All patients were satisfied with the reconstructive outcomes.The application of the perforator propeller flap sequential transfer technique can improve the repair ability of the lower extremity perforator propeller flap while ensuring the first-stage closure of the donor site, thereby improving the effectiveness.探讨穿支螺旋桨皮瓣连续转移技术用于下肢远端软组织缺损修复中的可行性和疗效。.2015年7月—2021年7月，收治10例下肢远端软组织缺损患者。其中，男8例，女 2 例；年龄 6～71 岁，中位年龄47岁。病因：恶性肿瘤切除后遗留创面5例，外伤3例，烧伤后瘢痕挛缩1例，糖尿病足溃疡1例。创面部位：胫前区1例，小腿远端和跟腱3例，足背和外踝4例，足跟1例，足底1例。创面范围为5 cm×3 cm～8 cm×8 cm。采用大小为14 cm×4 cm～29 cm×8 cm的腓动脉穿支螺旋桨皮瓣（第1皮瓣）修复下肢远端缺损；同时，于第1皮瓣近端另切取1块穿支螺旋桨皮瓣（第2皮瓣），大小为7 cm×3 cm～19 cm×7 cm，修复第1皮瓣供区；第2皮瓣供区直接拉拢缝合。.手术均顺利完成，第2皮瓣切取均在1 h内完成。术后10例第1皮瓣中，8例完全成活；1例出现静脉回流不畅致皮瓣远端坏死，采用皮片移植修复继发创面；1例出现静脉回流不畅，7 d后自行缓解。第2皮瓣均完全成活，未出现血肿、感染等并发症；创面Ⅰ期愈合。10例患者均获随访，随访时间2～39个月，中位时间15.5个月。皮瓣颜色、质地和厚度与受区相似，小腿轮廓未发生明显改变。随访期间肿瘤患者未见复发，瘢痕挛缩获得矫正，糖尿病足溃疡未见破溃。患者均对修复效果满意。.应用穿支螺旋桨皮瓣连续转移技术可以在提高下肢穿支螺旋桨皮瓣修复能力的同时，确保一期关闭供区，从而提高修复效果。.

To explore the reliability and effectiveness of prediction of the pedicle length of the proximally-based anterolateral thigh (pALT) flap which was used to repair the defects following the resection of various malignant tumors using computed tomographic angiography (CTA).The clinical data of 12 patients who met the selection criteria by using pALT flap to repair wounds left after malignant tumor resection between June 2015 and December 2020 were retrospectively analyzed. There were 5 males and 7 females; the age ranged from 16 to 80 years, with an average age of 54.4 years. After tumor resection, the soft tissue defect ranged from 15 cm×5 cm to 30 cm×12 cm; defect sites included 4 cases of lower abdomen, 3 cases of groin, 2 cases of thigh, and 3 cases of buttocks. Preoperative CTA was used to obtain the location information of the descending branch of the lateral femoral circumflex artery and its perforators by maximum density projection, and the length of the pedicle of pALT flap was estimated. Fasciocutaneous flap (5 cases) or myocutaneous flap (7 cases) were cut during operation to repair the defect, and the size of flap ranged from 20 cm×7 cm to 30 cm×12 cm. The donor site of thigh was directly sutured (11 cases) or repaired with skin graft (1 case). Bland-Altman analysis was used to detect the consistency between the pALT flap vascular pedicle length estimated by CTA and the pALT flap vascular pedicle length actually obtained during operation.One case had distal blood supply disturbance of the flap and was repaired with skin graft after debridement; the remaining 11 flaps survived. All donor and recipient incisions healed by first intention. All 12 cases were followed up 1-12 months, with an average of 4.3 months. One patient died of pelvic tumor recurrence at 6 months after operation, and no tumor recurrence was found in the other patients. Preoperative CTA estimated that the length of pALT flap vascular pedicle was 9.3-24.7 cm, with an average of 14.7 cm; the actual length of pALT flap vascular pedicle was 9.5-25.0 cm, with an average of 14.8 cm. Bland-Altman analysis showed that there was no significant difference between the pALT flap vascular pedicle length estimated by CTA before operation and the pALT flap vascular pedicle length actually obtained during operation, and the average difference was 0.1 (95% consistency limit: -0.89, 0.74), indicating that they had good consistency.CTA can be accurately used to localize the perforator and predict the possible pedicle length of the pALT flap. When performing a pALT flap surgery, preoperative CTA is helpful for surgeons to make a preliminary assessment of the difficult of the operation. The time for exploration of perforators and dissection of the vascular pedicle, and complications can be reduced, and the safety of the operation can be improved.探讨应用CT血管造影（CT angiography，CTA）行穿支血管定位及血管蒂长度预估，辅助近端蒂股前外侧（proximally-based anterolateral thigh，pALT）皮瓣设计，修复恶性肿瘤切除术后缺损的可行性。.回顾分析2015年6月—2020年12月应用pALT皮瓣修复恶性肿瘤切除后遗留创面且符合选择标准的12例患者临床资料。男5例，女7例；年龄16～80岁，平均54.4岁。肿瘤切除后软组织缺损范围为15 cm×5 cm～30 cm×12 cm；缺损部位：下腹部4例、腹股沟3例、大腿2例、臀部3例。术前采用CTA以最大密度投影获得旋股外侧动脉降支及其穿支的定位信息，预估pALT皮瓣血管蒂长度。术中切取筋膜皮瓣（5例）或肌皮瓣（7例）修复缺损，皮瓣切取范围为20 cm×7 cm～30 cm×12 cm；大腿供区直接拉拢缝合（11例）或植皮修复（1例）。应用Bland-Altman分析法检测CTA预估的pALT皮瓣血管蒂长度与术中实际获得的pALT皮瓣血管蒂长度之间的一致性。.术后1例出现皮瓣远端血运障碍，清创后应用植皮修复；余11例皮瓣全部成活。供受区切口均Ⅰ期愈合。12例均获随访，随访时间1～12个月，平均4.3个月。1例患者术后6个月因盆腔肿瘤复发死亡，余患者未见肿瘤复发。术前CTA预估pALT皮瓣血管蒂长度为9.3～24.7 cm，平均14.7 cm；术中实际获得的pALT皮瓣血管蒂长度为9.5～25.0 cm，平均14.8 cm。Bland-Altman分析示，术前CTA预估pALT皮瓣血管蒂长度与术中实际获得的pALT皮瓣血管蒂长度无显著差异，平均差值为0.1（95%一致限：−0.89，0.74），说明二者具有较好的一致性。.CTA可准确探查pALT皮瓣穿支血管位置，预估皮瓣血管蒂长度，从而减少术中穿支探查、血管蒂剥离时间，降低并发症发生率，提高手术安全性。.

To explore the feasibility and effectiveness of using the superior lateral genicular artery (SLGA) perforator propeller flap to reconstruct soft-tissue defects around the knee joint.Between October 2013 and May 2019, 10 patients underwent repairing of soft-tissue defects around the knee joint using the SLGA perforator propeller flap. There were 6 males and 4 males, with a median age of 34.5 years (range, 6-66 years). Etiologies included radical tumor resection in 4 cases, post-burn scar contracture in 3 cases, post-burn hypertrophic scar in 2 cases, and prothesis exposure after knee arthroplasty in 1 case. Defects located on the lateral knee in 6 cases, proximal lateral leg in 2 cases, popliteal fossa in 1 cases, and infrapatellar region in 1 case. The size of soft-tissue defects was from 6 cm×4 cm to 14 cm×8 cm. The extraction range of the flap was from 10.0 cm×5.5 cm to 23.0 cm×7.0 cm; the length of the perforator pedicle was 2.5-5.0 cm, with an average of 3.65 cm; the flaps were rotated 180°, the large paddle of the propeller flap was used to repair the defect, and the small paddle was used to assist the closure of donor site.Blister was observed in the distal 3-cm of one flap and the flap survived after conservative management. All the flaps survived, and the wounds in the donor and recipient areas healed by first intention. There was no vascular crisis, incision dehiscence, infection, or other complications. All 10 patients were followed up 4 to 48 months, with an average of 12.6 months. The color and texture of the flap were similar to those of the recipient area, and there was no need for secondary operation for degreasing and thinning. Scar contracture was corrected; no tumor recurrence was found in tumor patients; the artificial knee joint was preserved, the knee joint flexion and extension activities were good, and all the patient and family members were satisfied with the appearance and function of the lower limbs after operation.The SLGA perforator propeller flap surgery is relatively simple without the need of microvascular anastomosis, has the minimal donor-site morbidities, and can provide a compound flap for the repairing of a complex wound. The SLGA perforator propeller flap is one of the optional methods to repair soft-tissue defects around the knee joint.探讨应用膝上外侧动脉（superior lateral genicular artery，SLGA）穿支螺旋桨皮瓣修复膝关节周围软组织缺损的可行性及疗效。.2013年10月—2019年5月，应用SLGA穿支螺旋桨皮瓣修复膝关节周围软组织缺损10例。其中男6例，女4例；年龄6～66岁，中位年龄34.5岁。病因：肿瘤根治性切除4例，烧伤后瘢痕挛缩3例，烧伤后瘢痕增生2例，人工膝关节置换术后组织坏死假体外露1例。部位：膝关节外侧6例，小腿近端外侧2例，腘窝1例，髌骨下方1例。软组织缺损范围 6 cm×4 cm～14 cm×8 cm。皮瓣切取范围为10.0 cm×5.5 cm～23.0 cm×7.0 cm；穿支血管蒂长度为2.5～5.0 cm，平均3.65 cm；皮瓣均旋转180°。螺旋桨皮瓣的大桨修复缺损，小桨辅助供区关闭。.术后1例患者皮瓣远端3 cm处出现水疱，经常规换药后愈合。所有皮瓣全部成活，供受区创面均Ⅰ期愈合，无血管危象及切口裂开、感染等并发症发生。10例患者均获随访，随访时间4～48个月，平均12.6个月。所有皮瓣颜色、质地和厚度与受区相似，无需二次手术去脂修薄。瘢痕挛缩得到矫正；肿瘤患者未见肿瘤复发；人工膝关节得以保留，膝关节屈伸活动度良好。患者及家属对术后下肢外观及功能满意。.SLGA穿支螺旋桨皮瓣切取相对简单，无需显微血管吻合，供区损伤小，可以切取复合组织瓣，是修复膝关节周围皮肤软组织缺损可选择的方法之一。.

Background The latissimus dorsi myocutaneous flap is widely used in reconstructive surgery; however, primary donor-site closure remains challenging when a wide flap is harvested. Methods A large latissimus dorsi myocutaneous flap was elevated and transferred to repair defects. Perforators adjacent to the donor site of the myocutaneous flap were explored using an ultrasound Doppler probe or a technique of extensive exploration along the margins of the donor site wound. A single or multiple perforator propeller flaps based on these perforators were used to close the donor site defect. Results From June 2012 to April 2018, this method was used to restore posttraumatic and oncologic defects of the chest wall in 14 cases, upper extremity in 6 cases, and lower extremity in 1 case. The size and width of the latissimus dorsi myocutaneous flaps ranged from 16 × 11 cm to 33 × 17 cm (mean area, 335.6 cm) and 9 cm to 20 cm (mean width, 14 cm), respectively. The donor site defect was closed primarily by using a single flap in 11 cases, dual flap in 9, and triple flap in one. Donor site breakdown was not observed in any of the cases. Conclusions The perforator propeller flap could be used to reconstruct a latissimus dorsi myocutaneous flap donor site defect, ensuring not only the harvesting of a wide flap but also achieving primary donor site closure, thus greatly improving the versatility and capability of the latissimus dorsi myocutaneous flap in the reconstruction of large-sized defects.

Background Local and free flaps are most widely used in buttock reconstruction. However, local flaps and free flaps may not be appropriate for all complex soft tissue defects in buttock. In this study, we propose an alternative approach for buttock reconstruction and provide preliminary assessment in clinical efficacy of using a proximally based anterolateral thigh flap for buttock reconstruction. Methods In this study, we retrospectively analyzed the data of the patients with medium- to large-sized defects of buttock. All patients underwent buttock defect reconstruction using a proximally based anterolateral thigh flap between August 2012 and December 2020. Results Eight pedicled anterolateral thigh flaps were used to reconstruct buttock defects after tumor ablation in six patients, scar revision in one patient, melanocytic nevus resection in one patient. Flap size ranged from 25 × 8 cm to 30 × 12 cm, with pedicle length ranging from 12 to 20 cm. Flaps were elevated based on the distal musculocutaneous perforators from the descending branch of the lateral circumflex femoral artery and completely survived without any perfusion-related complications. We achieved satisfactory results from both the functional and aesthetic point-of-view at the 6-month follow-up in all cases. Conclusions The proximally based anterolateral thigh flap can be a valuable reconstructive option with sufficient tissue and a long vascular pedicle for buttock defect reconstruction.

To explore the reliability and effectiveness of soft tissue defect reconstruction using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle.Between December 2014 and December 2019, 13 patients underwent the reconstruction of soft tissue defects in various sites using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle. There were 10 males and 3 females, with an average age of 52.1 years (range, 29-83 years). Twelve wounds were resulted from resection of various malignant tumor, including 6 cases of head and neck tumors, 5 cases of shoulder and back tumors, 1 case of chest and back tumors. Among the 12 cases, 4 cases were complicated with wound infection and bone exposure, 1 case with skull defect and cerebral dura exposure, and 1 case with wound infection, skull necrosis, and cerebrospinal fluid leakage. One case was injured in a traffic accident, which resulted in infection wound in the back and shoulder and bone exposure. The sizes of the defect and musculocutaneous flap ranged from 11 cm×7 cm to 23 cm×15 cm and 25 cm×8 cm to 40 cm×14 cm, respectively. According to the spatial relationship between the donor and recipient sites, propeller flaps (8 cases) or percutaneous tunnel island flaps (5 cases) were used to transfer the myocutaneous flap to the recipient area to repair the wound. The donor site was directly closed and sutured in 9 cases, and those with excessive tension were repaired with free skin grafts in 2 cases or transferred flaps in 2 cases.After the operation, necrosis of the distal 4-cm of the musculocutaneous flap occurred in 2 cases. After debridement, the resultant wounds were reconstructed using a local flap and a posterior intercostal artery perforator flap, respectively. The remaining 11 myocutaneous flaps survived completely without arteries and veins crisis. The wounds in the donor and recipient areas healed by first intention. All the patients were followed up 1 to 48 months (mean, 7.4 months). The color and texture of the flap were good. During the follow-up, 1 patient underwent tumor resection again due to tumor recurrence, and 1 patient with a scalp hemangiosarcoma died due to unexplained thoracic hemorrhage. Tumor recurrence was not found in the remaining patients. The musculocutaneous flap coverage was stable and the infection was controlled.The lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle can be an alternation option to reconstruct refractory wounds with exposure of vital structures and organs and infection.探讨应用远端携带一部分背阔肌的下位斜方肌肌皮瓣带蒂移位修复不同部位缺损的可行性和疗效。.2014 年 12 月—2019 年 12 月，采用远端携带一部分背阔肌的下位斜方肌肌皮瓣修复不同部位缺损 13 例。其中男 10 例，女 3 例；年龄 29～83 岁，平均 52.1 岁。恶性肿瘤切除后遗留创面 12 例，其中头颈部肿瘤 6 例、肩背部肿瘤 5 例、胸背部肿瘤 1 例；4 例合并创面感染、骨外露，1 例合并颅骨缺损、硬脑膜外露，1 例合并创面感染、颅骨坏死、脑脊液漏。交通事故伤 1 例，导致肩背部感染创面、骨外露。创面范围为 11 cm×7 cm～23 cm×15 cm。肌皮瓣切取范围为 25 cm×8 cm～40 cm×14 cm。依据供、受区的空间位置关系，采取螺旋桨皮瓣（8 例）或经皮下隧道岛状皮瓣（5 例）移位方式，将肌皮瓣移位至受区修复创面。供区直接拉拢缝合（9 例），张力过大者行游离植皮（2 例）或转移皮瓣（2 例）修复。.术后 2 例肌皮瓣远端 4 cm 出现坏死，清创后 1 例采用局部皮瓣修复，1 例行转移肋间动脉穿支皮瓣修复；余 11 例肌皮瓣全部成活，无动静脉危象发生，供、受区创面Ⅰ期愈合。13 例均获随访，随访时间 1～48 个月，平均 7.4 个月。所有皮瓣颜色、质地良好。随访期间 1 例患者因肿瘤复发再次行肿瘤切除，1 例头皮血管肉瘤患者术后 4 个月因不明原因胸腔出血死亡；余肿瘤患者未见肿瘤复发，缺损处肌皮瓣覆盖稳定，感染控制。.远端携带一部分背阔肌的下位斜方肌肌皮瓣可用于修复合并重要组织、结构暴露及感染等难治性创面。.

The superficial temporal artery (STA) frontal branch flap is susceptible to venous congestion because of its unpredictable and variable outflow. The authors applied indocyanine green angiography in identifying the superficial temporal vessels to help surgeons with proper flap designs to avoid severe complications. A retrospective review from 2015 to 2020 was conducted. All the patients who underwent indocyanine green angiography before forehead flap transfer for facial defect reconstruction were reviewed. The STA and vein were observed using indocyanine green angiography preoperatively. The relationship between the artery and vein was investigated. The venous anatomy was analyzed to guide the pedicle design. The survival of the flap and complications were assessed. A total of 12 patients were identified and included in this study. Indocyanine green angiography allows clear visualization of the detailed anatomy of the STA and vein. The frontal branch of the vein had great variations and generally diverged from the arterial branch. The tiny venae comitantes provided sufficient drainage for 2 small forehead flaps. The frontal branch of the vein entered the forehead and was used as the outflow channel in 4 patients. The parietal branch of the vein, which consistently gave off secondary tributaries to the superior forehead, was included in the pedicle in 6 patients. All flaps survived without complications. Indocyanine green angiography provided accurate localization of the superficial temporal vessels. This technique may be helpful in the precise planning forehead flap surgeries and in avoiding the risk of venous congestion.

Objective This clinical study describes a reconstructive method for facial soft-tissue defects that uses the pre-expanded forehead flap and minimizes donor site morbidities. Methods The surgery was subdivided into 3 stages. First stage, an appropriately sized expander was buried underneath the forehead. Second stage, after adequate inflation of the expander, a forehead flap based on the frontal branches of the superficial temporal artery was raised, and the distal portion of the flap was used to reconstruct the facial defect. The cutaneous pedicle of the flap was designed near the frontal hairline. Third stage, 3 weeks later, the flap pedicle was divided, and the forehead incisional scar was melted into the neoreconstructed hairline. Results Between July 2010 and December 2016, 16 patients underwent facial defect reconstruction. Etiologies included postburn scar (31%), melanocytic nevus (56%), and hemangioma (13%). The mean size of the defects was 8.78 × 5.06 cm (range, 3 × 2.5 to 15 × 7 cm). The average dimension of the forehead flap was 21.63 × 7.38 cm (range, 12 × 4 to 28 × 10 cm). Fifteen flaps survived without any perfusion-related complications. Venous congestion occurred in 1 flap and gradually subsided without any flap loss. Patients were followed after surgery, ranging from 4 to 48 months. Patients and/or their family members were satisfied with the final aesthetic outcomes. Conclusion Facial defect reconstruction using a pre-expanded forehead flap, with the donor-site incisional scar designed along the hairline, can not only provide sufficient tissue for defect reconstruction, but also maximally reduce donor-site morbidities.

Successful raising of a distally based anterolateral thigh (dALT) flap mainly depends on a well-developed lateral circumflex femoral artery (LCFA) descending branch and an intact vascular connection between the descending branch and the vascular network of the knee. However, in some clinical scenarios, the descending branch is hypoplastic or the vascular connection of the knee is compromised. We present six cases of using dALT flaps in soft tissue defect reconstruction of the knee with either of the above-mentioned conditions. In these cases, the flaps relied on the reverse blood flow through the rectus femoris branch and showed complete survival postoperatively. We believe that the reverse flow from the rectus femoris branch could be an alternative blood supply for the dALT flap in the presence of hypoplasia of the LCFA descending branch or compromise of the vascular connection between the descending branch and the articular geniculate network.

Background The lateral circumflex femoral artery system with its anatomical variations is a common source vessel for numerous thigh flaps. However, the anatomic variations of the distally based thigh flaps have not been well classified. Methods Between July 2008 and July 2016, 19 patients (13 men and 6 women; age range, 3-58 years; mean, 27.5 years) underwent reconstruction of defects around the knee using distally based thigh flaps. Defect etiologies included malignant neoplasm (6 cases) and post-burn scar contracture (13 cases). The distally based thigh flaps were raised based on perforating vessels originating from the descending, oblique, rectus femoris branches of the lateral circumflex femoral artery. Results The average flap size was 17.7 × 8.4 cm (range, 9-24 cm × 6-13 cm), whereas the mean pedicle length was 16.2 cm (range, 8.5-25 cm). The flap's perforating vessels originated from the descending branch in 6 patients, the oblique branch from the descending branch in 7 patients, the rectus femoris branch in 5 patients, and the oblique branch from the transverse branch in 1 patient. All flaps were pedicle flaps except 1 based on the oblique branch from the transverse branch that was converted to a free flap. All flaps survived in its entity. Conclusions Our experience demonstrated that a distally based thigh flap can be reliably raised using perforating vessels from different branches of the lateral circumflex femoral artery.

Figure S2. The body weights of the animals of three groups over a 42 day post-operative period. (DOCX 1080 kb)

File S1 Methods and Figure legends of Supplementary Figures. (DOCX 15 kb)

Figure S1. Expression of a CDglyTK fusion gene in the tumor tissues at 15 days and at 42 days after SIEA flap transfection. (DOCX 6143 kb)

Background The authors' previous study showed that muscle-derived cells could regenerate strong engineered tendon with better tissue structure. However, little was known about the mechanism of neotendon built by muscle-derived cells, and the development and maturation of the cells. The authors hypothesized that mechanical loading modulated this process. The aim of this study was to investigate whether mechanical loading could regulate muscle-derived cell-based engineered tendon formation and maturation. Methods Muscle-derived cells were isolated, expanded, and seeded onto polyglycolic acid fibers that formed a cell-scaffold complex. After in vitro culture for 2 weeks, half of them were implanted without loading and the other half were sutured to mouse fascia that could provide a natural dynamic loading. At 12 and 24 weeks after implantation, histologic examinations, ultrastructure, and biomechanical characteristics were evaluated. Results Gross observation results showed that under mechanical loading, neotendon tissue could be generated with muscle-derived cells and the tissue structure became more mature with the increase of culture time. Well-organized aligned collagen fibers and elongated morphologic cells were observed on histologic examination under mechanical loading. In contrast, the nonload group failed to form neotendon, but formed disorganized fibrous tissue with significantly worse mechanical properties and poor collagen fibril structure. Conclusions This study demonstrates that mechanical loading is indispensable in tendon tissue engineering with muscle-derived cells. Although muscle-derived cells have a potential advantage in neotendon regeneration, stress deprivation resulted in a distinctly inferior maturity level of engineered tendon.

Summary Background The medial arm flap has a long history but remains underused despite providing multiple advantages. We reviewed our experience with using the medial arm flap to clarify the distribution of septocutaneous perforators and its relationship with pedicled flap design. Patients and methods This retrospective study included 36 consecutive patients who underwent reconstructive surgery with a medial arm flap (42 arms). Septocutaneous perforator mapping was conducted using a refined coordinate system originating at the medial epicondyle, with the y-axis running to the axillary apex. Results At least three perforators were identified along the medial intermuscular septum of the arm, located densely at 88 ± 8%, 49 ± 9%, and 20 ± 6% of the distance between the medial epicondyle and axillary apex (i.e., arm length), with a prevalence of 95.2%, 100%, and 85.7%, respectively. All arms had at least one medium- or large-sized perforator, and 90.5% of arms had at least two such perforators. Twenty-nine flaps were transferred as pedicled distant flaps for head and neck reconstruction or hand reconstruction, while the remaining 13 were transferred as perforator-based propeller flaps for axillary, elbow, or chest wall reconstruction. Thirty-six flaps underwent pre-transfer expansion. The average flap size was 157.9 ± 64.5 cm2 (range: 40–330 cm2). All flaps were successful, except for one perforator-based flap, which was replaced due to partial loss. Donor site morbidity was minimal. Conclusions Given its rich septocutaneous perforator distribution, the medial arm flap can be harvested reliably with versatile design and minimal donor site morbidity, thus deserving more attention in reconstructive surgery.

To explore the feasibility and technical points of soft tissue defect reconstruction of the lower extremity using the distally based anterolateral thigh (dALT) flap based on perforating vessels from the lateral circumflex femoral artery (LCFA) oblique branch.Between July 2010 and July 2016, 7 patients underwent defect reconstruction of the lower extremities using the dALT flap based on perforating vessels from the LCFA oblique branch. There were 4 males and 3 females with an average age of 26.7 years (range, 3-58 years). The etiologies included angiofibrolipoma in 1 case, malignant fibrous sarcoma in 1 case, soft tissue sarcoma in 1 case, and post-burn scar contracture in 4 cases. The disease duration was 13 years, 1 year, and 8 months in 3 patients with tumors respectively, and was from 6 months to 35 years in 4 patients with post-burn scar contracture. After resection of lesion tissues, the defect size ranged from 8 cm×6 cm to 24 cm×8 cm. The flap size ranged from 9 cm×7 cm to 24 cm×8 cm. The length of the pedicle ranged from 12 to 22 cm (mean, 16.6 cm). The distance from the flap pivot point to the superolateral border of the patella ranged from 9.5 to 14.0 cm (mean, 11.8 cm). The donor sites were directly closed in 6 cases and covered with the split-thickness skin graft in 1 case.All flaps survived after surgery without any major complications. All wounds at the donor and the recipient sites healed primarily. The patients were followed up from 5 to 54 months (mean, 30.7 months). The color, texture, and thickness of the flaps were similar to those of the surrounding skin. No tumor recurrence was observed. The range of motion of flexion and extension of the knee joint were greatly improved in the patients with post-burn scar contracture.For patients who have the oblique branch from the LCFA descending branch which sends out perforating vessels to the skin of the anterolateral thigh region, a dALT flap could be used to reconstruct soft tissue defects of the lower extremities.探讨以来自旋股外侧动脉降支的斜支为蒂的逆行股前外侧皮瓣（distally based anterolateral thigh flap，dALT）修复下肢皮肤软组织缺损的可行性及技术要点。.2010 年 7 月—2016 年 7 月实施的 18 例 dALT 皮瓣手术中，应用以来自旋股外侧动脉降支的斜支为蒂的 dALT 皮瓣修复下肢皮肤软组织缺损 7 例。男 4 例，女 3 例；年龄 3～58 岁，平均 26.7 岁。膝关节附近血管纤维脂肪瘤、恶性纤维组织细胞瘤、软组织肉瘤各 1 例，病程分别为 13 年、1 年、8 个月；烧伤后膝关节周围瘢痕挛缩 4 例，病程 6 个月～35 年。术中切除病变组织后遗留缺损范围为 8 cm×6 cm～24 cm×8 cm，皮瓣切取范围为 9 cm×7 cm～24 cm×8 cm；血管蒂长度为 12～22 cm，平均 16.6 cm；皮瓣旋转点至髌骨外上缘距离为 9.5～14.0 cm，平均 11.8 cm。供区直接拉拢缝合 6 例，植皮修复 1 例。.术后皮瓣及植皮均顺利成活，受区创面及供区切口均Ⅰ期愈合。患者均获随访，随访时间 5～54 个月，平均 30.7 个月。皮瓣颜色、质地与受区周围皮肤相似。随访期间肿瘤患者无肿瘤复发，关节周围瘢痕挛缩患者伸屈功能及外观明显改善。.如斜支来自旋股外侧动脉降支，具有足够长度共干血管，同时斜支发出皮肤穿支血管至股前外侧区，则可以选择以斜支为蒂的 dALT 皮瓣修复下肢皮肤软组织缺损。.

To explore the feasibility and effectiveness of sideburn reconstruction using the expanded island scalp flap based on the parietal branch of the superficial temporal vessel.Between February 2012 and April 2015, 7 patients underwent sideburn reconstruction. There were 3 males and 4 females with an average age of 15 years (range, 4-44 years). The etiologies included burn injury in 3 cases, trauma in 1 case, radiation therapy in 1 case, and congenital melanocytic nevus in 2 cases. The size of the sideburn defects ranged from 5.0 cm×3.5 cm to 16.0 cm×10.0 cm. At the first-stage, according to the sideburn defect, a tissue expander of the appropriate size was inserted beneath the superficial temporal fascia which containing the parietal branch of the superficial temporal vessel. Postoperatively, regular saline injection was commenced. After 3-6 months of the first-stage surgery, the expander was adequately inflated. While the second-stage surgery was performed, the lesion was excised and the tissue expander removed. The expanded island scalp flap based on the parietal branch of the superficial temporal vessel was harvested and advanced towards the defect of the sideburn according to the contralateral normal one, and the size of flap ranged from 8 cm×3 cm to 17 cm×11 cm. The donor site was closed primarily.All flaps survived and the wound and donor sites were healed primarily without any complication. All patients were followed up 1-36 months (mean, 9.8 months). The profile, hair density, and hair direction of the new sideburn were similar to the contralateral sideburn. In 1 patient, the reconstructed sideburn was a little larger than the contralateral normal one. After laser hair removal, the patient was satisfied with the appearance.The expanded island scalp flap based on the parietal branch of the superficial temporal vessel provides an effective option for the sideburn reconstruction, which presents with the similar appearance to the contralateral one.探讨应用以颞浅血管顶支为蒂的头皮岛状瓣再造鬓角的可行性和临床疗效。.2012 年 2 月—2015 年 4 月，收治 7 例拟再造鬓角患者。男 3 例，女 4 例；年龄 4～44 岁，平均 15 岁。烧烫伤后瘢痕 3 例，外伤瘢痕 1 例，血管瘤同位素放射治疗后瘢痕 1 例，先天性色素痣 2 例。鬓角缺损范围为 5.0 cm×3.5 cm～16.0 cm×10.0 cm。一期根据鬓角区皮肤软组织缺损大小，在包含颞浅血管顶支的正常头皮组织下埋置皮肤软组织扩张器，术后定期注水扩张；一期术后 3～6 个月，待扩张头皮达到预期修复所需组织量时，二期手术取出扩张器，切取以颞浅血管顶支为蒂的头皮岛状瓣修复鬓角软组织缺损，皮瓣范围为 8 cm×3 cm～17 cm×11 cm。供区直接拉拢缝合。.术后皮瓣均顺利成活，受区创面及供区切口均 Ⅰ 期愈合。患者均获随访，随访时间 1～36 个月，平均 9.8 个月。再造鬓角形态、毛发密度、毛发生长方向与对侧正常鬓角相似。1 例术后皮瓣毛发超出原有发际线，经激光脱毛处理外观满意。.应用以颞浅血管顶支为蒂的扩张头皮岛状瓣修复鬓角区皮肤软组织缺损，再造鬓角外观与对侧正常鬓角相似，是一种有效修复方法。.

To explore the feasibility and technical essentials of soft tissue defect reconstruction of the lower extremity using the distally based anteromedial thigh flap (dAMT) pedicled with perforating vessels from rectus femoris branch.Between July 2008 and December 2015, 6 patients underwent defect reconstruction of the lower extremity using the dAMT flap pedicled with perforating vessels from rectus femoris branch. There were 4 males and 2 females with an average age of 34 years (range, 4-55 years). The etiologies included liposarcoma in 1 case, malignant fibrous histocytoma in 1 case, post-burn scar contracture around the ankle in 1 case, and post-burn scar contracture around the knee in 3 cases. The disease duration ranged from 3 to 28 months (mean, 13 months). After resection of lesion tissues, the defect size ranged from 13 cm×7 cm to 24 cm×12 cm. The flap size ranged from 15 cm×8 cm to 24 cm×12 cm. The length of the pedicle ranged from 10 to 25 cm (mean, 19.8 cm). The distance from the flap pivot point to the superolateral border of the patella ranged from 8 to 13 cm (mean, 11.3 cm). The donor sites were directly sutured.All flaps survived postoperatively without any complications. All wounds at the donor and the recipient sites healed primarily. The patients were followed up from 5 to 36 months (mean, 17.8 months). The color, texture, and thickness of the flaps were similar to those of the surrounding skin. No tumor recurrence was observed. The range of motion of flexion and extension of the joint were greatly improved in the patients with scar contracture.If the rectus femoris branch gives off cutaneous branch to the anteromedial thigh region and arises from the descending branch of the lateral circumflex femoral artery, a dAMT flap could be raised to reconstruct soft tissue defects of the lower extremity.探讨以股直肌支穿支为蒂的逆行股前内侧皮瓣（distally based anteromedial thigh flap，dAMT）修复下肢皮肤软组织缺损的可行性和技术要点。.2008年7月-2015年12月，应用以股直肌支穿支为蒂的dAMT皮瓣修复下肢皮肤软组织缺损6例。男4例，女2例；年龄4～55岁，平均34岁。腘窝脂肪肉瘤1例，膝关节前内侧恶性纤维组织细胞瘤1例，烧伤后踝关节周围瘢痕挛缩1例，烧伤后膝关节周围瘢痕挛缩3例。病程3～28个月，平均13个月。术中切除病变组织后遗留缺损范围为13 cm×7 cm～24 cm×12 cm，皮瓣切取范围为15 cm×8 cm～24 cm×12 cm；血管蒂长度为10～25 cm，平均19.8 cm；皮瓣旋转点至髌骨外上缘距离8～13 cm，平均11.3 cm。供区直接拉拢缝合。.术后皮瓣均顺利成活，受区创面及供区切口均Ⅰ期愈合。无手术相关并发症发生。患者均获随访，随访时间5～36个月，平均17.8个月。皮瓣颜色、质地和厚度与受区皮肤相似。随访期间肿瘤患者无复发，关节周围瘢痕挛缩患者关节伸屈功能及外观明显改善。.如股直肌支来自旋股外侧动脉降支且两者共干，同时股直肌支发出皮肤分支至股前内侧区，可以选择以降支远端为蒂的dAMT皮瓣修复下肢皮肤软组织缺损。.

This clinical study aimed at introducing a reconstructive method for total cheek soft tissue defects using the pre-expanded medial arm flap and to maximally reduce donor site morbidities simultaneously. A retrospective review of data was performed for 3 patients requiring the pre-expanded medial arm flap to reconstruct total cheek defects. The donor site in the medial arm was primarily closed using a pedicle parascapular or thoracodorsal artery perforator flap. All patients had a total unilateral cheek defect after lesion removal. Three pre-expanded medial arm flaps measuring 17 × 11 cm, 22 × 15 cm, and 20 × 15 cm were separately used for cheek defect reconstruction. The donor sites in the medial arm were closed using a pedicle parascapular flap, measuring 22 × 9.5 cm, and 2 pedicle thoracodorsal artery perforator flaps, measuring 22 × 10 cm and 23 × 10 cm. No major complications occurred in any patient. Patients were followed up for 3, 12, and 18 months. Patients (and/or their family members) were satisfied with the final outcomes. Total cheek defect reconstruction using a pre-expanded medial arm flap, with the donor site closed using a pedicle axial back flap, can not only provide sufficient tissue for cheek resurfacing, but also guarantee primary donor site closure and could be an alternative reconstructive option for patients who have a total cheek defect.

Elbow reconstruction is challenging for reconstructive surgeons. The purpose of this report is to present the results of the use of freestyle perforator-based propeller flap designed from the medial arm region for elbow reconstruction. The defects following soft tissue sarcoma resection at the medial and posterior elbow were repaired in two patients. The dimensions of the defects were 11 × 7 cm2 and 10 × 7 cm2. Two perforators were identified in each case using Doppler ultrasound probe in the medial arm, adjacent to the defect. The perforator with visible pulsation was chosen as the pedicle vessel, which was 12-cm and 7-cm proximal to the medial epicondyle. An elliptical flap, extending almost the full length of arm, was raised and rotated 180° to repair medial elbow defects. The sizes of the flaps were 17 × 8 cm2 and 11 × 7 cm2. The donor sites were closed directly. Both flaps survived; temporary venous congestion occurred in one case. There were no other postoperative complications. These cases illustrated that the medial arm flap might be used for reconstruction of medial elbow defects with this freestyle perforator-based propeller flap design. © 2014 Wiley Periodicals, Inc. Microsurgery 35:411–414, 2015.

The authors have previously demonstrated promising results with tissue engineered trachea in vitro using decellularized matrix scaffolds. The present study aims to investigate the applicability of the construct in vivo.Tracheae harvested from Brown Norway rats (donor) and Lewis rats (recipient) were decellularized with repeated detergent-enzymatic treatment cycles. Decellularized Brown Norway tracheal matrix scaffolds were seeded with Lewis rat stem cell-derived chondrocytes externally and tracheal epithelial cells internally to generate a bilaminated tracheal construct. Brown Norway tracheal matrix scaffolds (n = 6), Lewis rat scaffolds (n = 6), and the engineered constructs (n = 3) were implanted subcutaneously in Lewis rats and observed for 4 weeks. Fresh Brown Norway (n = 6) and Lewis rat (n = 6) tracheae were implanted as controls. Histologic analysis for macrophage, CD8, and CD4 cell infiltration was performed.Allogeneic decellularized matrix scaffold showed significantly decreased macrophage, CD8+ and CD4+ cell infiltration compared with tracheal allografts, and demonstrated similar level of cell infiltration to syngeneic decellularized matrix scaffold. No significant differences in macrophage infiltration were observed between syngeneic decellularized matrix scaffolds and tracheal isografts. The engineered constructs achieved complete epithelial cell coverage and preserved lumen patency; however, chondrocytes failed to repopulate the cartilaginous matrix with statically seeding stem cell on scaffold.Decellularized tracheal matrix scaffold did not induce significant allograft rejection or foreign body reaction in vivo. Although the construct supported reepithelialization, stem cell-derived chondrocytes failed to engraft in the heterotopic environment and represent a focus of future investigations.

The medial upper arm flap is a time-honored yet ignored technique. It may be revitalized by combining the techniques of tissue expansion and perforator flap surgery. Pre-expansion increases flap dimension, remodels flap vasculature, and reduces donor site morbidities, making the medial arm flap a more effective option for various defect reconstructions. A pre-expanded brachial artery perforator flap achieves excellent functional and aesthetic outcomes in patients with soft tissue defects on the head and neck, axilla, chest wall, and upper extremity. Although this technique requires multiple procedures, each operation is relatively simple and has a low complication rate when properly performed.

To explore the feasibility and technical essentials of soft tissue defect reconstruction following malignant tumor removal of limbs using perforator propeller flaps.Between July 2008 and July 2015, 19 patients with malignant limb tumor underwent defect reconstruction following tumor removal using the perforator propeller flaps. There were 13 males and 6 females with an average age of 53.4 years (range, 20-82 years). The disease duration ranged from 1 to 420 months (mean, 82 months). The tumors located at the thigh in 10 cases, at the leg in 2 cases, at the arm in 1 case, at the forearm in 1 case, around the knee in 2 cases, and around the elbow joint in 3 cases. Totally 23 flaps (from 8 cm x 3 cm to 30 cm x 13 cm in size) were used to reconstruct defects (from 4 cm x 4 cm to 24 cm x 16 cm in size). The potential source arteries included the femoral artery (n = 2), profunda femoral artery (n = 3), superficial circumflex iliac artery (n = 1), lateral circumflex femoral artery (n = 6), superior lateral genicular artery (n = 2), peroneal artery (n = 2), anterior tibial artery (n = 1), brachial artery (n = 4), and radial artery (n = 1). The remaining one was a free style perforator flap.Partial distal flap necrosis occurred in 3 cases after surgery with rotation angles of 180, 150, and 100 degrees respectively, which were reconstructed after debridement using a free-style perforator flap in 1 case and using free skin grafting in the other 2 cases. The other 20 flaps survived completely after surgery. Primary healing of incisions was obtained at the donor and recipient sites. There was no severe complication such as infection, hematoma, and total flap failure. All patients were followed up 3 months to 5 years (mean, 19 months). One patient with malignant melanoma around the elbow joint had tumor recurrence, and underwent secondary tumor resection. The appearance, texture, and color of the flaps were similar to those at the recipient site.For patients with malignant tumor of the limb, the perforator propeller flap can be an alternative option for soft tissue defect reconstruction after tumor resection, with the advantages of relatively simple operation and remaining the main vessels.

The pedicled paraumbilical flap is a reliable tissue transfer for hand and forearm reconstruction. However, its size, pedicle length and/or thickness limit its application in resurfacing of extensive defects of the upper limb. To conquer those limitations, this flap was pre-expanded for 10-24 weeks prior to transfer in 25 patients and used as a pedicle flap to cover upper extremity defects. Extensive defects of upper limb were reconstructed by the pre-expanded paraumbilical flaps. The flaps ranged in size from 10 cm × 8 cm to 30 cm × 14 cm. The donor sites were closed directly in all cases. All flaps survived, but two had partial flap necrosis due to venous congestion or infection. With pre-transfer expansion, a large, well-perfused abdominal pedicle flap can be raised and transferred based on the paraumbilical perforators. This pre-expanded flap might be useful in the patients who have the extensive upper limb defects and sufficient time to allow tissue expansion.

Summary Background Closure of donor-site defects from large cutaneous flap harvesting often faces significant morbidity, which limits the utility of workhorse flaps in large-soft-tissue defect reconstruction. To overcome this limitation, we introduced the concept of a second ‘buddy' flap to reconstruct the donor-site defect. Methods Between 2007 and 2010, the buddy flap concept was applied in 12 patients. In each case, the primary flap, which included the latissimus dorsi myocutaneous flap, parascapular flap, transverse rectus abdominis myocutaneous flap, superficial inferior epigastric artery flap and anterolateral thigh flap, was transferred to repair the primary defect. In addition, a secondary pedicle flap, either an axial flap or a perforator flap, was chosen as a buddy flap for closure of the donor-site defect. Results The primary defects ranged from 10 × 7 to 35 × 20 cm in size. Donor-site closure was accomplished using buddy flaps with preserved normal contour and acceptable scars. Additional time for the buddy flap harvesting and insetting was within 1 h. All flaps survived completely. There were three cases with complications, such as seroma, wound infection and haematoma, which were managed accordingly without compromising the viability of flaps. Conclusions The buddy flap approach achieved reliable coverage of large donor-site defects with low morbidity and excellent aesthetic results. This technique allows reconstructive surgeons to harvest large cutaneous flaps without being limited by significant donor-site morbidity. We demonstrate that this technique can diminish the concern regarding donor-site defect in large soft-tissue reconstruction.