Arc Of Rotation Research Articles

Improvement of rotational arc during deep flexion range of a novel designed polyethylene insert for posterior-stabilised total knee arthroplasty

BackgroundOne of the remaining issues in total knee arthroplasty (TKA) is achieving sufficient rotational arc during deep flexion range of the knee for specific postures such as the ‘seiza’ or cross-legged sitting. This study aimed to evaluate whether there was a change in the actual in vivo rotational arc during deep flexion range before and after a design change of polyethylene (PE) inserts. MethodsIn 50 posterior-stabilised TKA cases, knee kinematics, including rotational movement, were measured intraoperatively using an image-free navigation system to compare a newly designed PE insert with reduced the posterior lip with a conventional PE insert. Femoral–tibial rotational angles at 30°, 45°, 60°, 90°, 120°, and 130° knee flexion were evaluated. Varus/valgus instability, knee range of motion, and femoral rollback were also measured. Obtained parameters were compared between new and conventional PE inserts. The independent factors associated with rotational arc during deep flexion range (120° and 130° knee flexion) were analysed using multivariate analysis. ResultsThe newly designed PE insert demonstrated a significant increase in the rotational arc at 120° (22.9 ± 8.7° vs. 30.1 ± 11.9°, P < 0.001) and 130° (24.3 ± 9.5° vs. 32.5 ± 12.4°, P < 0.001) knee flexion compared with that with the conventionally designed posterior-stabilised insert. Multivariate analysis demonstrated that using the newly designed PE insert was an independent predictor of improved rotational arc during deep flexion range: regression coefficient was 11.2 (95% confidence interval 7.1–15.3, P < 0.001). ConclusionThe design change, which reduced the posterior lip of the PE insert, contributed to improved rotational arc in 120° and 130° deep flexion ranges.

Effect of arc rotation on the enhancement of mechanical properties of ER70S6 in WAAM

Inceptive studies were done on using Rotational/Spin arc technique for Wire Arc Additive Manufacturing (WAAM). A wall of low alloy steel was build and the effect of rotating the arc on the mechanical properties and the microstructural properties were studied. Tensile testing conducted across multiple directions shows an average tensile strength of 550 MPa which is comparatively higher by approximately 90 MPa than other stationary arc techniques used to fabricate the same material, however with lesser percentage elongation. Microhardness testing revealed that the average hardness of the build to be 156 HV0.5. Microstructural studies revealed reduction in grain sizes and random grain orientation; with the misorientation and rotation angle plots exhibiting the presence of High Angle Grain Boundaries (HAGB's), which could be attributed as the primary factors for the improvement in the tensile properties.

The treatment of axillary hidradenitis suppurativa with a thoracodorsal artery perforator V-Y advancement flap: a case report

Hidradenitis suppurativa, a recurrent and chronic inflammatory skin disease, presents with extensive scars and multiple abscesses. Moreover, axillary hidradenitis suppurativa could be impacted by scar contracture, which can limit arm mobility. The most reliable treatment for advanced hidradenitis suppurativa is meticulous and radical excision. Several methods exist for the reconstruction of axillary wounds after reconstruction. Skin grafts are an option, but their drawbacks include secondary contracture and poor aesthetic results. Local flaps could be useful, but also have a limited arc of rotation for larger defects. Thoracodorsal artery perforator (TDAP) flaps have been proven to be very effective as part of the armamentarium for axillary wounds. Herein, we describe the use of a TDAP flap in a V-Y advancement fashion with minimal pedicle dissection. We only dissected the perforator pedicle about 1 to 2 cm from its muscle entry point. With this maneuver, the flap could be easily moved to cover the defect without vascular compromise. We found that the TDAP flap performed in a V-Y fashion, with a propeller design, was very useful for an axillary defect over an island. This procedure was simple, easy, and time-saving.

Возможности применения подподбородочного лоскута для реконструкции нижней губы

Head and neck reconstruction surgery is a challenging area of surgery that requires the surgeon to be familiar with various reconstructive options. Achieving both functionality and aesthetic harmony of facial proportions constitutes one of the most important aspects of the head and neck defect elimination. For that various methods are used involving application of local, regional and free flaps on vascular pedicles. The reconstructive method is selected based on the defect size, location, composition, as well as on the age, comorbidity, surgeon’s and patient’s preferences. Submental flap is a regional flap that has proven to be a reliable fasciocutaneous flap, the tissues of which are identical to that of the lower face in width, texture, and color. Long vascular pedicle ensures wide flap rotation arc, thereby allowing one to use the flap for elimination of defects of the upper and lower lips, mental region, tongue, floor of the mouth, and preauricular area. Damage to the donor site is minimal, it is cosmetically invisible due to the scar hidden in the mental region. The paper presents the results of surgical treatment of the 38-year-old female patient with the soft tissue defect of the lower third of the face and the lip resulting from trauma. The wound did not heal for more than six months, no improvement was observed. It was decided to eliminate the defect using a rotation submental flap. The patient was followed up for a year after surgery. We managed to achieve complete aesthetic and functional rehabilitation of the patient.

Role for Wrist Hemiarthroplasty in Acute Irreparable Distal Radius Fracture in the Elderly.

Volar locking plates for distal radius fracture (DRF) in the elderly may show complications in the most comminuted osteoporotic cases. The authors provide criteria for DRF in elderly that may not be amenable to volar plating ("irreparable DRF") and review the current results of a preliminary series of wrist hemiarthroplasty for these injuries. Between 2011 and 2019, 28 wrists with acute irreparable intra-articular DRF were treated with wrist hemiarthroplasty (96% female, mean age 79years). A total of 17 wrists with a mean follow-up of 32months were reviewed. At follow-up, mean visual analog scale (VAS) pain was 1/10, mean forearm rotation arc was 148°.

Deep Learning-Based Dose Prediction Model for Automated Spot-Scanning Proton Arc Planning

Spot-scanning proton arc (SPArc) is a novel technique that employs a planning optimization algorithm to select the energies and positions of spots along a dynamic rotational arc trajectory. The SPArc technique has the potential to achieve superior dose conformality and treatment delivery efficiency over intensity-modulated proton therapy. However, creating such a SPArc plan using existing approaches is time-consuming and computationally extensively. This study investigated the feasibility of using the deep learning (DL) technique to predict the 3D dose distribution of the SPArc treatment plan, leveraging the prior knowledge acquired from conventional intensity-modulated radiation therapy (IMRT) plans. A DL model, 3D-Unet with residual connections and attention gates, was trained using an open-source database of CT images, critical structures, and IMRT plans from 340 head and neck cancer patients (HNC) as the base model. Transfer learning technique was applied to fine-tune the model parameters using the SPArc treatment plans created on the HNC patients from an in-house dataset, where the SPArc treatment plans (including control point sampling, energy layer distribution, arc trajectory, etc.,) were optimized using a previously developed iterative approach. The performance of the DL model was evaluated by comparing predicted and planned doses over 17 SPArc treatment plans by using 4-fold cross-validation. The SPArc planning time per patient was 8∼12 hours, while the dose prediction time was reduced to 2∼3 minutes using the proposed DL model. The deviation of D95 in the target was (-1.8±1.6) %. The deviation of the mean dose in the parotids, cord, mandible, and brainstem were (2.5±6.5) %, (-0.5±4.3) %, (1.4±3.9) %, and (3.4±8) % of the prescription, respectively. The dice similarity coefficients of the 80%, 70%, and 60% isodose lines were (0.9±0.09), (0.93±0.01), and (0.94±0.01), respectively. Our results demonstrate that a DL-based dose prediction model can be created with a limited number of SPArc treatment plans through transfer learning. The DL model can directly predict the 3D dose distribution in minutes for automated planning. This study paves the roadmap to develop a quick clinical decision platform for the optimal selection among the multi-treatment modalities.

Patient outcome scores between 1,2- and 2,3-intercompartmental supra-retinacular artery (ICSRA) pedicled vascularised bone grafts (PVBGs) in the treatment of proximal pole scaphoid fracture non-union – a questionnaire study

BackgroundNumerous studies have been published on the use of 1,2-intercompartmental supra-retinacular artery (ICSRA) as a pedicled vascularised bone graft (PVBG) in scaphoid fracture non-union, however, only very few studies have reported their results of 2,3-ICSRA. The aim of this study was to compare the patient-rated outcome scores between these two PVBGs in proximal pole scaphoid fracture non-union.MethodsNineteen patients who underwent surgery for scaphoid non-union between 2017 and 2021 at a single institution were recruited retrospectively in this study. All patients were operated by a one senior orthopaedic surgeon. A mailed questionnaire with the modified mayo wrist (MMW) and the patient rated wrist evaluation (PRWE) scores were sent to the patients.ResultsAll patients were males with a mean age of 22.5 years. There was no statistically significant difference in the PRWE score between the two PVBGs. However, a statistically significant difference was found in the MMW score, with the 1,2-ICSRA PVBG having better scores.ConclusionDespite the 2,3-ICSRA having a longer arc of rotation, longer nutrient arteries, and is technically easier to incorporate in a PVBG, when compared with the 1,2-ICSRA it did not result in better patient-rated outcome scores.

Distally Based Pedicled Fibula Flap for Reconstruction of Distal Tibia After Oncological Resection: A Case Series and Review of Literature.

Reconstruction of distal tibial defects pose a difficult challenge because the bone is subcutaneous and close to the tendons and neurovascular bundles. Distally based pedicled fibula with retrograde flow can be used for the reconstruction of distal tibial defects. This is based on the communicating branch of the peroneal artery to the posterior tibial artery. We present three cases of distal tibia primary tumours which were resected and reconstructed using recycled autograft plus distally based pedicled fibula and ankle arthrodesis. This pedicled retrograde fibula flap is a novel technique for the reconstruction of distal tibial defects after oncological resections. It provides a vascularized graft without the need for microvascular surgery and without violating the normal limb. Meticulous dissection of and preservation of the communicating branches between the peroneal artery and the posterior tibial artery with confirmation of retrograde flow before dividing the proximal peroneal pedicle is sine quo non for the success of this graft. This flap overcomes the drawback of the limited arc of rotation and limited reach of proximal pedicle-based flap for distal tibial reconstruction. Long-term functional outcomes, limb shortening associated with this flap, and its effect on functional outcomes remain to be ascertained.

Efficacy and Versatility of the Medial Hemisoleus Flap for Complex Middle Third Tibial Defects: A Presentation of 2 Cases

Soft tissue injuries involving the middle third of the tibia can present significant clinical challenges, often leading to complications such as infection and nonunion. This article explores the efficacy of the medial hemisoleus flap as a valuable surgical technique for addressing these complex wounds. Two case reports are presented to illustrate the successful use of this flap in clinical practice. The medial hemisoleus flap offers consistent blood supply, improved arc of rotation, and reduced donor site morbidity, making it an excellent choice for reconstructive surgery in this anatomical region. In the first case, a 17-year-old patient with a history of smoking developed an open fracture in his left leg two years after a car accident, which led to a soft tissue defect with exposed bone in the middle third of his left leg. In the second case, a 25-year-old male involved in a traffic accident presented with a displaced open bone fracture of the middle third of the tibia and fibula with bone sequestrum. Surgical technique, advantages, patient selection criteria, and outcomes are discussed, highlighting the significance of the medial hemisoleus flap in addressing these challenging wounds.

Tracheoesophageal Fistula Closure in a Pediatric Patient Using a Supraclavicular Artery Island Flap.

Acquired tracheoesophageal fistulas can lead to large defects with fatal complications. Surgical management is challenging but necessary to prevent respiratory infections and poor weight gain. Therefore, a reliable and pliable flap like the pedicled supraclavicular artery island flap with its wide arc of rotation and robust vascularization is needed for reconstruction. We highlight the surgical technique and postoperative measures in managing a tracheoesophageal fistula due to button battery ingestion in a 9-month-old boy with the supraclavicular artery island flap. In summary, the supraclavicular artery island flap is a safe and successful tool for closure of large acquired tracheoesophageal fistulas in pediatric patients.

Endoscopic Reconstruction of the Sellar Floor by Extended Inferior Turbinate Flap in Recurrent Pituitary Tumors.

Objective This aim of this study was to address the outcome of endoscopic reconstruction of the sellar floor by extended inferior turbinate flap. Patients and Methods This is a retrospective study of 34 patients with a recurrent pituitary tumor. They were treated between March 2018 and December 2021 by endoscopic extended endonasal approach with the reconstruction of the sellar floor by an extended posterior pedicle inferior turbinate flap. The clinical and radiological follow-up was performed immediately postoperation and regularly every 3 months up to 1 year, and the available data from the last follow-up visit were included in the analysis. Results The patients' age ranged between 40 and 65 years, with a slight female predominance (55.9%). Headache was the main presentation (47.1%), and functional tumors were found in 50.0% patients. Visual disturbances were field defects among 61.8% and papilledema among 52.9% patients. Preoperative endoscopy revealed postseptectomy as the significant finding (73.5%), followed by postseptectomy and adhesion (14.7%) and finally postseptectomy and hypertrophied inferior turbinate (11.8%). Total tumor resection was achieved in 76.5%, visual improvement was recorded in 52.9%, and no complications were reported in 82.4% patients. Cerebrospinal fluid (CSF) leak was not reported in any of the studied patients. Finally, total resection was significantly associated with younger age, non-functioning tumor and improvement of headache. Conclusion The extended inferior turbinate flap is an effective and safe approach for sellar floor reconstruction in endoscopic endonasal surgery for recurrent pituitary tumors. The extension overcomes the relatively small inferior flap and its limited arc of rotation.

Exposed Distal Tibia Coverage by Reversed Soleus Muscle Flap: Our Experiences

Reconstruction of the exposed lower third tibia and ankle region remains a difficult task and a challenge for reconstructive surgeons. Microsurgical flaps have been the method of choice for this reconstruction, but in our hospital, we do not have equipment or a microsurgical-trained team for this type of procedure. Moreover, free muscle flaps have more risk of failure and sometimes the patient's clinical condition does not allow a more complex surgery in some cases. Local muscle flaps are preferred in these situations. MethodologyThis study was carried out in the Burn and Plastic Surgery Department, Rajshahi Medical College Hospital, Rajshahi from July 2015 to December 2021 on 100 patients ( 89 males and 11 females with ages ranging between 21 and 62 years). Patients with tibial defects in the distal third of the tibia which need soft tissue coverage were selected. ResultsOur study shows that reversed medial hemisoleus muscle flap had an excellent outcome with short surgical duration, easy implementation, excellent resolution, and low morbidity of the donor area. Moreover, preservation of the lateral portion is suitable for plantar flexion showing a long arc of rotation. ConclusionMedial hemisoleus muscle flap is a reliable option for the reconstruction of soft tissue defects with the exposed bone of the distal leg based on perforators of the posterior tibial artery. Careful flap dissection with preservation of as many perforators as possible is the key to success.

Inferior and Medially Based Breast Parenchymal Rotation Flap: A New Mastopexy Technique for Replacing Breast Volume After Breast Implant Explantation.

Recently, a growing number of patients have been opting for the removal of breast implants. This often results in a degree of volume loss that can vary from mild to substantial, contingent on the size of the implant, with many patients requiring a mastopexy. Although autoaugmentation mastopexy serves as the primary surgical approach to restore shape and fill the void left by the implant, the fullness attained with the implant cannot be replicated through autoaugmentation. Our goal was to present the technical details and utilization of an inferomedial pedicle-based breast parenchymal flap, without rotational restriction from the parenchyma, for autoaugmentation after explantation. A retrospective chart review was performed of 12 patients who underwent surgery with this technique between the years of 2019 to 2022, with emphasis on reasons for explantation, early and late complications, and satisfaction scores on a Likert scale. Capsular contracture was the most common reason for explantation, and only 2 patients experienced minor wound dehiscence in the early postoperative period. With a mean follow-up of nearly 2 years, no bottoming out was encountered in any of the patients, and satisfactory breast shape was obtained. Further, postoperative satisfaction was significantly higher than preoperative satisfaction. The inferomedial-based parenchymal rotation flap is a new procedure that can be applied in this patient group because of its wide rotation arc and reliable vascularity. It is also an effective option for creating the desired conical breast shape in patients who do not want breast implants over the long term.

Can convertible metal-backed glenoid components replace cemented polyethylene glenoid components in anatomical total shoulder arthroplasty?

BackgroundAnatomical total shoulder arthroplasty (aTSA) has been used to manage degenerative diseases such as primary osteoarthritis. An increase in the use of this procedure has led to several developments in humeral and glenoid components to improve patient outcomes. This study aimed to compare clinical and radiological outcomes of the newly-introduced convertible metal-backed glenoid components with cemented polyethylene glenoid components in aTSA, and to determine whether the new component would be comparable to a conventional one for reducing the burden of future revision or conversion surgeries.MethodsMedical records of fifty patients who underwent aTSA with at least two years of follow-up were retrospectively reviewed. Eighteen patients received convertible metal-backed glenoid components with vitamin E1-coated liner (MB group), while thirty-two patients received conventional cemented polyethylene glenoid components (PE group). Pre- and postoperative clinical and radiological outcomes (acromion-greater tuberosity angle [AGA] and humeral lateral offset [LO]) at final follow-up were assessed. Radiolucent lines (RLLs) and loosening around the humeral and glenoid components were also evaluated.ResultsClinical outcomes improved after surgery in both groups (all p < 0.001). The arc of rotation measured by AGA improved postoperatively in both groups (all p < 0.001), and AGA and LO were not different according to the type of glenoid components (all p > 0.05). Overall complication rates including RLLs of PE and MB groups were 43.8% (14/32) and 16.7% (3/18), respectively (p = 0.031). Although the PE group had more RLLs than did the MB group (p < 0.05), related symptoms and/or glenoid implant loosening were not observed in both groups. Subscapularis failure occurred in two patients in the PE group and in one in the MB group.ConclusionThe convertible metal-backed glenoid implant with vitamin E1-coated liner may be a good alternative for considering the potential for an easier conversion to reverse total shoulder arthroplasty.

Single-Stage Extensor Digitorium Tendon Reconstruction, Including Overlying Soft Tissue Defects of the Foot Dorsum with a Composite-Free Anterolateral Thigh Flap

Abstract Background Loss of the extensor tendon with overlying soft tissue remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with defect coverage by soft tissue flaps, meets the goals of approaching functionality, and achieves an esthetic result. Patients and Methods From June 2016 to June 2022, our center submitted six patients to a one-stage procedure correcting the extensor tendon and skin defect using a composite-free anterolateral thigh (ALT) flap with fascia lata (FL). Results The ALT skin paddle was from 10 × 8 cm to 26 × 13 cm, and all flaps included vascularized FL with an average of 12 × 9.5 cm, which was split and folded to reconstruct as a tendon. The extensor digitorium brevis tendon defects were reconstructed by fascia sheets in all patients. One patient had additional reconstruction of the extensor hallucis longus tendon. All the flaps survived completely, and no complication was reported. All patients received rehabilitation therapy starting in the third week postoperatively. The mean follow-up was 33.67 months (range, 10–60). The mean arc of ankle rotation between dorsiflexion and plantar flexion was 49.20 degrees (range, 40–55 degrees). After reconstruction, our patients showed good functional results, and these patients could walk, climb stairs, tiptoe again without support, and regular footwear could be worn. Conclusion A composite-free ALT flap with vascularized FL is a reasonable option for coverage of the extensor tendon and overlying soft tissue defects. It helps reduce the surgical risk and hospitalization time and provokes faster recovery and rehabilitation. Level of Clinical Evidence Case studies, Level 4.

How to get the most out of your gastrocnemius and soleus flaps

Summary: Gastrocnemius and soleus flaps represent the workhorse local flaps to cover soft tissue defects of the proximal 1/3 and middle 1/3 of the leg, respectively. An important consideration before conducting a local flap is whether the flap can provide adequate coverage. The utility of the gastrocnemius flap can be increased using multiple techniques to increase the arc of rotation including the posterior midline approach, dissection at the pes anserinus and medial femoral condyle origin, scoring the fascia, and inclusion of a skin paddle. Concerning the soleus flap, the hemisoleus flap represents a technique to increase the arc of rotation. With a soleus flap, one must consider the soft tissue defect location, size, and perforator blood supply because these factors influence what soleus flap technique to use. This article discusses how to make the most out of gastrocnemius flaps and soleus flaps regarding maximizing coverage and ensuring successful flap outcome.

Can Hip Passive Range of Motion Predict Hip Microinstability? A Comparative Study

Background: Hip microinstability is an increasingly recognized cause of pain and disability in young adults. It is unknown whether differences in passive hip range of motion (ROM) exist between patients with versus without hip microinstability. Hypothesis: Underlying ligamentous and capsular laxity will result in differences in clinically detectable passive ROM between patients with femoroacetabular impingement (FAI), patients with microinstability, and asymptomatic controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review of all patients undergoing hip arthroscopy between 2012 and 2018 was conducted. Patients with a diagnosis of isolated microinstability based on intraoperative findings were identified and classified as having isolated FAI, instability, or FAI + instability. Patients without a history of hip injury were included as controls. Range of motion was recorded in the supine position for flexion, internal rotation, and external rotation. Univariate and multivariate analysis was performed on each measurement in isolation as well as combinations of motion to include total rotation arc, flexion + rotation arc, and flexion + 2× rotation arc Models were then created and tested to predict instability status. Results: In total, 263 hips were included: 69 with isolated instability, 50 with FAI, 50 with FAI + instability, and 94 control hips. A higher proportion of patients in the instability and FAI + instability groups were female compared with the FAI and control groups ( P &lt; .001). On univariate analysis, differences were found in all groups in all planes of motion ( P &lt; .001). Multivariable analysis demonstrated differences in all groups in flexion and flexion + rotation arc. In symptomatic patients, the best performing predictive model for hip microinstability was flexion + rotation arc ≥200° (Akaike information criterion, 132.3; P &lt; .001) with a sensitivity of 68.9%, specificity of 80.0%, positive predictive value of 89.1%, and negative predictive value of 51.9%. Conclusion: Patients with hip microinstability had significantly greater ROM than symptomatic and asymptomatic cohorts without hip microinstability. Symptomatic patients with hip flexion + rotation arc ≥200° were highly likely to have positive intraoperative findings for hip microinstability, whereas instability status was difficult to predict in patients with a flexion + rotation arc of &lt;200°.

Impact of Electrode Rotation on Aluminum GMAW Bead Shape

Aluminum gas metal arc welding (GMAW) uses inert shielding gas to minimize weld pool oxidation and reduce susceptibility to porosity and incomplete fusion defects. For aluminum shipbuilding, naval welding requirements highly recommend the use of helium-argon mixtures or pure helium shielding gas to provide a broader heat field and better weld toe fusion. Pure argon shielding gas can be used but has been susceptible to incomplete fusion and porosity defects, where argon’s lower thermal conductivity promotes a narrower arc heat field and shallow weld fusion depth. Using helium is a concern because it is a finite resource that costs approximately five times more than argon. The rotating electrode pulsed GMAW process was investigated to improve argon shielding fusion characteristics and reduce helium usage. Argon-shielded bead-on-plate tests were used to evaluate the relationship between ER5183 electrode rotation parameters and arc power on constant deposit area bead shape. These tests were compared to stringer beads (no oscillation) that were made with argon, helium, and helium-argon shielding gases. Electrode rotation improved underbead fusion depth width and toe fusion. With preferred rotation parameters, the bead width and incomplete fusion at weld toes were equivalent to helium-based welds. For weld reinforcement, electrode rotation promoted a nonsymmetric profile with deposit bias on the bead side, where rotation direction was aligned with travel direction. The bead-side deposit bias is an advantage based on preliminary horizontal V-groove welding procedures using ceramic backing. Electrode rotation can offset the effects of gravity, promoting a smoother bead and fusion profile.

Modified trilobed transposition flap for a distal nasal defect.

Reconstruction of a distal nasal defect is challenging due to poor skin mobility and the potential for nasal alar retraction. A trilobed flap can utilize more mobile proximal skin, increase the total rotational arc, and decrease the tension associated with flap transposition. However, the trilobed flap may not be ideal for distal nasal defects because each flap is designed using immobile skin, which may lead to flap immobility and free margin distortion. To overcome these problems, the base and tip of each flap were extended further from the pivot point than those of the conventional trilobed flap. Herein, we report the use of the modified trilobed flap to treat 15 consecutive cases of distal nasal defects that occurred from January 2013 to December 2019. The mean duration of follow-up was 15.6 months. All flaps survived completely, and satisfactory aesthetic outcomes were achieved. No complications such as wound dehiscence, nasal asymmetry, or hypertrophic scarring were observed. The modified trilobed flap is a simple and reliable treatment for distal nasal defects.

Refinements in the Preexpanded Distant Flap for Giant Melanocytic Nevi of the Upper Extremity in Pediatric Patients.

Surgical treatment of large and giant congenital melanocytic nevi (GCMN) of the upper extremity is challenging because of limited options for reconstruction. A preexpanded distant flap is considered an important option in upper extremity reconstruction, where the soft tissue available for use is limited. The authors aimed to refine the preexpanded distant flap after excision of the GCMN in the upper extremity. Large (>10 cm) and giant (>20 cm) congenital melanocytic nevi of the upper extremities treated with tissue expansion and distant flaps over 10 years were retrospectively reviewed, and the authors describe in detail the surgical strategies for reconstruction of the upper extremity with a distant flap. From March of 2010 to February of 2020, 13 patients (mean age, 2.87 years) treated with 17 preextended distant flaps were included. The mean flap dimension was 154.87 cm 2 , ranging from 15 × 5 to 26.5 × 11 cm. All procedures were successfully completed except for one, in which partial flap necrosis occurred. Preconditioning was performed before flap transfer in 5 patients with larger rotation arcs and flap dimensions. The mean duration of postoperative follow-up was 51.85 months. A new reconstructive protocol was proposed that combined the 3 elements, including a distant flap, tissue expander, and preconditioning. In the treatment of GCMN in the upper extremities, careful planning and multiple stages are required. For pediatric patients, the preextended distant flap with preconditioning is useful and effective for reconstruction. Therapeutic, IV.