Flap Area Research Articles

Perfusion Changes in Perforator-Based Propeller Flaps

AbstractBackground To cover soft tissue defects, the perforator-based propeller flap offers the option to rotate healthy tissue into complex wounds. By rotating the flap, the perforator is torqued. As a result, perfusion changes are possible.Methods A retrospective data analysis of patients was done, who received a propeller flap to cover soft tissue defects of the lower extremity as well as a peri- and postoperative perfusion monitoring with a laser-Doppler-spectrophotometry system. Additionally, patient-specific data were collected.Results Seven patients were identified. Four patients experienced early complications, two epidermolysis of the distal flap areas, three wound healing disorders, and one partial flap necrosis. Intraoperative perfusion monitoring showed a decline of blood flow after incision of the flap, especially at distal flap site. In case of complications, there were prolonged blood flow declines up to the first postoperative day.Conclusion Torqueing the perforator by rotating the flap can cause an impairment in inflow and outflow. If the impairment is prolonged, perfusion-associated complications are possible. The identification of a viable perforator is particularly important. In addition, a conservative postoperative mobilization is necessary to compensate for the impaired and adapting outflow.

Neurotization of the radial forearm free flap improves swallowing outcomes in hemiglossectomy defects.

We examined the effect of free tissue neurotization on speech and swallowing outcomes for patients undergoing reconstruction of hemiglossectomy defects with a radial forearm free flap (RFFF). A retrospective study was performed in patients with oral cavity squamous cell carcinoma undergoing a hemiglossectomy and reconstruction with a RFFF. Functional outcomes including nutritional mode, range of liquids and solids, and speech understandability were analyzed 1-year post-treatment. Eighty-four patients were included in this analysis, 41 of whom had neurotized flaps (49%). No significant differences in demographic or clinical variables were seen between the neurotized and non-neurotized groups. On multivariate analysis controlling for BMI, flap area, and N-classification, patients with neurotized flaps were significantly more likely to have normal range of liquids and solids and less likely to have a G-tube. Neurotization of RFFF reconstructing hemiglossectomy defects results in decreased G-tube dependence and improved range of liquids and solids.

Low Donor Site Morbidity Supports the Use of Infraumbilical Flaps for Head and Neck Reconstruction: A Retrospective Cohort Study

Background: Currently, the standard design of the skin component of abdominal soft-tissue flaps recommended for head and neck reconstruction encompasses the upper and lower periumbilical region to include the maximum number of myocutaneous perforators. Yet, this flap design precludes the harvest of bilateral flaps and the use of the contralateral area in case of flap failure. Aim: We aimed at proving the long-term safety of infraumbilical abdominal free flaps in terms of abdominal wall integrity. Methods: Consecutive subjects who underwent reconstruction of composite cervico-facial defects with infraumbilical free flaps between 2008 - 2020 were enrolled. After surgery, patients were followed up at three-month intervals to evaluate the incidence of any complications at the donor site. Results: 25 patients underwent reconstruction with free flaps from the lower abdomen. A total of 35 abdominal flaps were performed; ten patients underwent bilateral flap harvest. Marginal abdominal skin necrosis occurred in 3 patients. Abdominal bulge occurred in one case; neither hernia nor abdominal wall weakness was encountered at a median follow-up of 12 months. Conclusions: The infraumbilical region is a safe donor area of free flaps for head and neck reconstruction that preserves abdominal wall firmness and provides a satisfactory cosmetic result at the donor site.

VisuMax Flap 2.0: a flap plus technique to reduce incidence of an opaque bubble layer in femtosecond laser–assisted LASIK

PurposeTo evaluate the incidence of an opaque bubble layer (OBL) in femtosecond laser–assisted in situ keratomileusis (FS-LASIK) flaps created with VisuMax Flap 2.0 as a result of a modification in the parameters of the flap programming.MethodsThis retrospective study was comprised of 1400 eyes of 715 patients who received FS-LASIK surgery. OBLs were measured and reported as a percentage of the flap area to identify the incidence and extent. Flap creation, which is a modification technique, was performed with 8.1-mm flap diameters plus 0.3-mm enlarged interlamellar photodisruption (group Flap 2.0). The same flap diameters without extra photodisruption as the previous standard setting were also implemented (group Flap 1.0). The preoperative measurements, including sphere, cylinder, keratometry, and intraoperative characteristics such as flap size and thickness, were documented. Possible risk factors for the occurrence of OBLs were investigated in this study.ResultsThe incidence of an OBL was reduced when using the Flap 2.0 program (31.4%) compared to the Flap 1.0 program (63.7%). The area of hard and soft OBLs created by the Flap 2.0 program is smaller than those created by the Flap 1.0 program (P = 0.007 and P < 0.001). Multivariate logistic regression indicated that a thinner flap (P = 0.038) and a higher sphere (P = 0.001) affected the chance of hard OBLs occurring.ConclusionThe VisuMax Flap 2.0 program promotes gas venting by enlarging the interlamellar photodisruption size. The incidence and extent of OBLs appear to be reduced significantly when the Flap 2.0 program is applied.

Characteristics and Limitations of Video-capillaroscopy in Reconstructive Microsurgery for Different Histologic Components of Flaps.

Indocyanine green, ultrasonography, and handheld Doppler can be used to evaluate blood flow at the donor and recipient site during microvascular reconstruction. However, these methods do not provide direct visualization and assessment of real-time blood flow. Video-capillaroscopy has been shown to be useful in clinical practice to assess microcirculation in rheumatologic disorders. In this report we used video-capillaroscopy to assess different tissue components involved in microvascular surgery. Seven patients who underwent head and neck oncologic microvascular reconstruction between November 2021 and February 2022 were included in this study. Video-capillaroscopy (GOKO-BscanZD, GOKO Imaging Devices Co., Ltd., Japan) was used to evaluate the donor-site and recipient-site tissue components. Optimal red blood cell movement was graded with a score of four, while no flow was graded with a score of 0. Seven myocutaneous flaps and seven recipient sites were evaluated. For the donor-site, our analysis demonstrated a significantly higher video-capillaroscopy quality for skin (3.43), adipose tissue (3.7) and perforators (3.7) when compared with muscle (0.429), muscle fascia (0.857), and de-epithelialized skin (1) (P < 0.001). For the recipient-site, a significantly higher video-capillaroscopy quality for skin (2.7), adipose tissue (3.5), and the periosteum (2.1) was noted when compared with muscle (0) (P < 0.001). Video-capillaroscopy efficiency is limited in the muscular component and injured (de-epithelialized) skin surface areas of flaps. Herein, we provide evidence that assessment of flap perfusion with video-capillaroscopy can be reliably achieved in the skin, periosteum, perforators, and adipose tissue. Video-capillaroscopy is expected to be applied for intraoperative real-time blood flow evaluation.

8281 Anterior Cul-De-Sac Obliteration: Dissection of a Difficult Bladder Flap

<h3>Study Objective</h3> This video highlights techniques for dissection of an obliterated anterior cul-de-sac in a patient undergoing hysterectomy. <h3>Design</h3> N/A. <h3>Setting</h3> This surgery was performed at a tertiary academic referral center. <h3>Patients or Participants</h3> This is a 56-year-old with history of 3 cesarean sections and a large central anterior fibroid who has failed medical management for abnormal uterine bleeding. <h3>Interventions</h3> The patient underwent a robotic-assisted hysterectomy with bilateral salpingo-oophorectomy. The fibroid was densely involved in adhesions to the bladder flap area. The colpotomy cup was not visible. The posterior leaf of the broad ligament was incised to skeletonize the uterine artery. This posterior approach helped show both the artery and the colpotomy cup. The anterior leaf of the left broad ligament was dissected. Filmy serosal attachments along the fibroid were taken down. This process was repeated on the right side. There were thick attachments near the adhesive band, and bleeding was encountered. To decrease the vascular supply to the uterus, bilateral uterine arteries were ligated. Subsequently, the band was taken down with minimal blood loss. This is typically the area of the thickest scar tissue. The surgeon can place an instrument inferior and lateral to the adhesions and create a tunnel to guide the dissection. We backfilled the bladder with sterile saline to clearly delineate the extent of the adhesions. Once the scar was incised, the bladder flap was further developed. The uterine arteries were separated and the colpotomy was completed. The vaginal cuff was closed, and the procedure was concluded. <h3>Measurements and Main Results</h3> The patient was seen for 3 years for medical management, and she opted for surgery due to ongoing symptoms. She was seen for a 6-week follow-up visit. <h3>Conclusion</h3> It is imperative to safely dissect the bladder away from the uterus in cases of anterior obliteration. Techniques include backfilling the bladder, approaching adhesions laterally and inferiorly, and de-vascularizing uterus.

Use of intra operative fluorescein dye for prediction of flap viability.

A successful flap is dependent on its vascularity. During dissection, flap viability may become compromised due to inadequate perfusion from the vascular pedicle(s) on which the flap is based. Various methods have been proposed to determine viability of a flap both, intraoperatively and postoperatively. The ideal method must be simple, accurate, reproducible and safe. The purpose of this study was to study the role of fluorescein dye for prediction of flap viability.Materials &amp; Methods: Thirty patients undergoing flap coverage for various defects were evaluated. Flaps were elevated and evaluated clinically for viability. Intravenous fluorescein was injected into the patients prior to flap inset and its course through the flap was monitored under ultraviolet light. Fluorescent areas were marked intraoperatively (size and location documented). Areas of viable flaps were documented on post-operative day 5 and comparisons made. The area of viable flap as determined using intra operative fluorescein dye administration corresponded to surviving flap area on post-operative day 5, in 27 of the 30 cases studied, giving positive predictive value of 90%. Overall, the dye had an accuracy of 99.03% compared to intraoperative clinical flap assessment accuracy of 95.70%. Marginal necrosis was seen in 16.6 % of all cases. No allergic reaction to the dye was observed. - Accurate assessment of flap viability is an area of constant research. Use of intraoperative fluorescein dye for prediction of flap viability has an accuracy of 99.03% compared to intraoperative clinical flap assessment accuracy of 95.70%. In a few cases, the dye is prone to underpredict the area of viable flap tissue. The dye can be used to corroborate clinical asessment of viable flap tissue when used intraoperatively. The dye was found to be safe and easy to use.

Comparative study of the effects between second toe tibial dorsal artery flap and second toe tibial plantar proper artery flap in repairing finger skin and soft tissue defects

Objective: To compare the effects between second toe tibial dorsal artery flap (2-TDAF) and second toe tibial plantar proper artery flap (2-TPPAF) in repairing finger skin and soft tissue defects. Methods: A retrospective cohort study was conducted. From January 2019 to June 2020, 27 patients with skin and soft tissue defects at the fingertips with area of 1.5 cm×1.2 cm-2.6 cm×1.8 cm after debridement who met the inclusion criteria were admitted to Suzhou Ruihua Orthopaedic Hospital, including 21 males and 6 females, aged 19-59 (37±10) years. According to flap repair methods used in the defective fingers, the patients were divided into 2-TDAF group (12 cases) and 2-TPPAF group (15 cases). The area of 2-TDAF ranged from 1.5 cm×1.2 cm to 2.5 cm×1.6 cm, and the area of 2-TPPAF ranged from 1.7 cm×1.3 cm to 2.6 cm×1.8 cm. Full-thickness skin grafts from the medial side of the ipsilateral leg were grafted to the wounds in donor sites, and the wounds in donor sites of skin grafts were directly sutured. Flap arterial diameter, flap excision time, flap survival situation of patients in 2 weeks after operation, and follow-up time were recorded. At the last follow-up, the two-point discrimination distance of flap graft site, total action motion (TAM) of the finger joints, and wound healing of the flap donor site were recorded; the Vancouver scar scale (VSS) was used to score the scar in donor area of the second toe and the recipient area of fingers; the appearance and self-satisfaction subscales of the Michigan hand outcomes questionnaire (MHQ) were used to evaluate the affected finger. Data were statistically analyzed with independent sample t test or Fisher's exact probability test. Results: The flap artery diameter of patients in 2-TDAF group was 0.35-0.80 (0.56±0.14) mm and the flap cutting time was (14.0±2.7) min, which were significantly shorter than 0.80-1.35 (1.02±0.16) mm and (19.7±3.4) min in 2-TPPAF group (with t values of 7.81 and 4.79, respectively, P<0.01). The flaps of patients in the 2 groups in recipient areas survived well in 2 weeks after operation, and the wounds in donor areas of flaps of patients in the 2 groups healed well at the last follow-up. There was no statistically significant difference in the postoperative follow-up time, and two-point discrimination distance of flap graft site, TAM of the finger joints, VSS score of scar in the second toe donor site and the finger recipient site, and the appearance and self-satisfaction of MHQ scores of the affected finger at the last follow-up (P>0.05). Conclusions: Compared with 2-TPPAF, 2-TDAF has a shallower anatomical layer and shorter time for surgical flap removal, which can preserve the proper arteries and nerves at the base of the toes and reduce the damage to the donor site.

Restoration of Sensibility Following Reconstruction of Soft Tissue Defect of Thumb with the First Dorsal Metacarpal Artery Island Flap

Introduction: Thumb injuries constitute a challenge for the plastic surgeon because the loss of its function compromises the function of the entire upper limb. If there is a soft tissue defect in thumb where tendons, joints, or bones is exposed, it requires stable vascularized flap reconstruction preferably with a local or regional flap. The First Dorsal Metacarpal Artery (FDMA) island flap from the dorsum of the index finger is an option for reconstructing such thumb defect. Objectives: To assess the quality of sensitivity at flap site following reconstruction of soft tissue defect in thumb with the FDMA island flap. Materials and Methods: A prospective observational study was conducted from July 2012 to June 2013 among 31 patients admitted with soft tissue defect of thumb with exposure of tendon, bone, joint or loss of pulp and were treated with innervated FDMA island flap. Recovery of sensation was evaluated by static-2PD test. Results: Out of 31 patients 28 were male and 3 were female with male to female ratio is 9:1. The mean age was 26.2±8.8 years. A large number of patient was manual worker (construction worker, mechanic). Most of them sustained injury in their dominant thumb (61%). Most common cause of injury was electric burn (78%) rest were due to machinery injury. Average s-2PD over the flap area 9.1 mm (range, 8-12 mm) compared with 7.4 mm (range, 7-11 mm) over the donor site of opposite index finger and 5.5 mm (range, 3-9 mm) over corresponding site of opposite thumb. Average loss of s-2PD over the flap area compared with the donor area was 1.4 mm (19.2%). Every patient was satisfied with the outcome. Conclusion: Restoration of sensibility is quite satisfactory after reconstruction of soft tissue defect of thumb by first dorsal metacarpal artery island flap. JAFMC Bangladesh. Vol 18, No 1 (June) 2022: 34-38

Application of lateral upper arm free flap in the repair of postoperative defects of oral cancer

Objective: To explore the clinical application and efficacy of lateral upper arm free flap (LUAFF) for one-stage repairing of soft tissue defect after oral cancer surgery. Methods: This article was a retrospective analysis of clinical data of 46 patients receiving treatment of one-stage repairing of soft tissue defect with LUAFF after oral cancer surgery in Hunan Cancer Hospital, from June 2019 to June 2021. Among these cases, 40 were males, and 6 were females. The patients' ages were from 23 to 64 years old. The clinical data of patients were reviewed and outcomes were evaluated. SPSS 23.0 software was used for statistical analysis. Results: In the LUAFF of 46 patients, flap area ranged from 5.0 cm×3.5 cm to 15.0 cm×7.0 cm; the mean pedicle length was 8.15±1.42 cm; the mean artery diameter was 1.20±0.41 mm (range, 1.5 to 2.5 mm); the mean diameter of the largest veins was 2.15±0.52 mm; and the median number of perforators was 2.6 (range, 1 to 4). All donor sites were closed primarily. Two cases had arterial anastomosis thrombosis, but their flaps were successfully saved with urgent re-anastomosis of the vessels. The overall flap survival rate was 93.5%(43/46), with flap necroses after operation in three cases. No patient received tracheotomy. The average hospital stay time of patients after operation was 9.4 days. The follow-up time was 6-24 months, elbow and wrist movements on the operative side were normal, and the upper limb muscle strength was not affected. Conclusions: LUAFF is a suitable choice for the repairs of small-moderate tissue defects in oral cancer surgery, with consistent perforators in the flap, simple harvest method, concealed donor-site scar, and high survival rate.

A Modified Scapular-Parascapular Flap Design for Optimal Coverage of the Residual Limb.

Large soft tissue defects associated with major limb amputation pose a challenge to the reconstructive surgeon due to the 3-dimensional contour of the residual limb and the need to withstand the unnatural shear forces imparted by prosthetic sockets. Fasciocutaneous flaps based on the circumflex scapular system have proven useful for residual limb coverage due to the durability of the tissue provided, the absence of functional morbidity, and the ease of reelevation. A modified, bilobed flap design that incorporates large Burrow triangles into each limb serves to leverage the perforasome anatomy of the posterior trunk to provide maximal 3-dimensional coverage and favorable flap geometry while also facilitating donor site closure. A retrospective medical record review was performed for all patients who underwent reconstruction of a residual limb after major amputation using the modified, bilobed scapular-parascapular free flap design at Walter Reed National Military Medical Center between 2018 and 2021. A computer-based application was used to calculate flap area and dimensions based on photographs of preoperative and intraoperative markings. Six patients with varying amputation levels (2 transtibial, 1 transfemoral, 1 hip-disarticulation, 1 hemipelvectomy, 1 transradial) underwent soft tissue coverage using the modified flap design. Mean flap area was 318.4 cm 2 with 51.1 cm 2 attributable to the modified design. This represents a 16% increase over a conventional bilobed design. There were no partial or complete flap failures. The modified scapular-parascapular flap design enables harvest of a larger and more versatile fasciocutaneous flap with geometry that is well suited for coverage of the residual limb.

Alteration of a radial forearm flap to adjust to the superficial radial artery: a case report

Aberrant branches of the radial artery at the level of the forearm have rarely been reported. Preoperative workups to identify aberrant branches of this type have also seldom been performed. However, surgeons elevating a radial artery-based flap should consider the possibility of aberrant arterial branching. Otherwise, the circulation of both the flap and hand may be endangered. We present a case of an anomalous radial artery branch that resulted in an intraoperative alteration of the flap design. A novel technique was used to preserve the circulation of the entire flap, and the patient recovered with adequate healing of the flap and donor areas. No hand function deficits or subjective complaints were noted. In conclusion, surgeons should be aware of the superficial radial artery or other aberrant branches of the radial artery that may be located in various locations during radial artery-related flap elevation.

Efficacy of Exosome Adipose-Derived Stem Cells (ACSs-Exosome) on Skin Flaps Transplantation in Plastic Surgery: A Systematic Literature Review

Background: Exosomes are a small subset of extracellular vesicles with a size of about 50 nm – 200 nm, which are found in many body fluids. The exosome is rich in various proteins and is a cargo that carries out the process of transporting and transporting between cells in the context of cell communication. This becomes a potential new therapeutic modality in triggering the modulation and activity of target cells so that ACSs-Exosome becomes a new potential to modulate skin flap transplantation repair in plastic surgery.&#x0D; Methods: The literature search process was carried out in various databases (PubMed, Web of Sciences, EMBASE, Cochrane Libraries, and Google Scholar) regarding the use of ASCs-exosome in skin flap transplantation repair in plastic surgery cases.&#x0D; Results: A total of 5 studies were included in this systematic review. In general, ASCs-exosome administration was more effective in the percentage of flap survival area than in the placebo group. There are 3 studies that state that the effectiveness of flap area survival is more than 70 percent compared to the placebo group, which is only in the range of 30-40 percent.&#x0D; Conclusion: ASCs-exosome has the potential to be developed to improve the survival rate of skin flap transplantation in the case of plastic surgery.

Reconstruction of Large Soft Tissue Defects in the Distal Lower Extremity: Free Chain-Linked Bilateral Anterolateral Thigh Perforator Flaps versus Extended Latissimus Dorsi Musculocutaneous Flaps.

Background: Reconstruction of the large soft-tissue defects in the lower extremity still constitutes a challenge for plastic surgeons. This retrospective study was conducted to compare the surgical and clinical outcomes of the chain-linked bilateral anterolateral thigh perforator flaps and extended latissimus dorsi musculocutaneous flap in the reconstruction of the large soft tissue defects of the lower extremity. Methods: From January 2012 to December 2021, 34 patients aged between 20 and 66 years received chain-linked bilateral anterolateral thigh perforator flaps (15 cases) or extended latissimus dorsi musculocutaneous flaps (19 cases) for the reconstruction of extensive soft-tissue defects in the lower extremity. The two groups were homogeneous in terms of age, etiology, comorbidities, and flap area. In addition, the intraoperative data, outcomes, complications, and long-term follow-up results were collected and analyzed. Results: The extended latissimus dorsi musculocutaneous flap group had a shorter operation time (271.8 ± 59.5 min vs. 429.6 ± 51.9 min), harvest time (58.9 ± 24.8 min vs. 152.7 ± 41.4 min), and anastomosis time (27.2 ± 10.4 min vs. 53.7 ± 8.1 min) than the chain-linked bilateral anterolateral thigh perforator flaps group (p < 0.05). Based on patient self-assessment, the donor site temporary muscle weakness in the extended latissimus dorsi musculocutaneous flap group was significantly more than that in the chain-linked bilateral anterolateral thigh perforator flaps group (p < 0.05). Conclusion: Both methods can repair large defects and restore the function of the injured limbs at a single stage. However, considering the operation time and flap-harvesting time, the authors recommend the extended latissimus dorsi musculocutaneous flap, especially for those who cannot tolerate a prolonged surgery.

Oxidative stress-induced endothelial cells-derived exosomes accelerate skin flap survival through Lnc NEAT1-mediated promotion of endothelial progenitor cell function

BackgroundFlap transplantation is commonly used in reconstructive surgery. A prerequisite for skin flap survival is sufficient blood supply. However, such approaches remain unclear. This study aimed to explore the underlying mechanisms of exosomes derived from human umbilical vascular endothelial cells (HUVECs) exposed to oxidative stress on endothelial progenitor cells (EPCs) and their subsequent influence on the survival of skin flaps.MethodsHUVECs were treated with various concentrations of H2O2 to establish an oxidative stress model. To investigate the effects of H2O2-HUVEC-Exos and HUVEC-Exos, Cell Counting Kit-8, tube formation, invasion assays, and quantitative real-time polymerase chain reaction (qRT-PCR) were performed in EPCs. Microarray analysis was used to reveal the differentially expressed long non-coding RNAs (lncRNAs) in the H2O2-HUVEC-Exos and HUVEC-Exos. In addition, gene silencing and western blotting were employed to determine the mechanism behind lncRNA nuclear enrichment enriched transcript 1 (Lnc NEAT1) in EPCs. Further, a rat skin flap model was used to determine the role of the exosomes in skin flap survival in vivo.ResultsHUVECs were stimulated with 100 μmol/L H2O2 for 12 h to establish an oxidative stress model. H2O2-HUVEC-Exos promoted the proliferation, tube formation, and invasion of EPCs and remarkably increased skin flap survival compared to the HUVEC-Exos and control groups. Sequencing of exosome RNAs revealed that the Lnc NEAT1 level was dramatically increased in the H2O2-HUVEC-Exos, leading to activation of the Wnt/β-catenin signaling pathway. Comparatively, knockdown of Lnc NEAT1 in HUVEC-Exos and H2O2-HUVEC-Exos significantly inhibits the angiogenic capacity of EPCs, reduced the survival area of skin flap and downregulated the expression levels of Wnt/β-catenin signaling pathway proteins, whereas Wnt agonist partly reversed the negative effect of NEAT1 downregulation on EPCs through the Wnt/β-catenin signaling pathway.ConclusionsExosomes derived from HUVECs stimulated by oxidative stress significantly promoted the pro-angiogenic ability of EPCs through the Wnt/β-catenin signaling pathway mediated by Lnc NEAT1 and hence enhanced random flap survival in vivo. Therefore, the application of H2O2-HUVEC-Exos may serve as an alternative therapy for improving random skin flap survival.

The Promising Effect of Topiramate on Random-Pattern Skin Flap Survival in Rats.

Partial necrosis of skin flaps following plastic and reconstructive surgeries is one of the major problems in these medical interventions. This study was conducted to evaluate the beneficial effects of topiramate an anti-epileptic agent on ischemic random skin flaps. Twenty-four Wistar rats were provided and randomly divided into four experimental groups (control group and low-, intermediate- and high-dose treatment groups). A rat random-pattern skin flap model was performed in all groups, and animals in the low-, intermediate- and high-dose experimental groups were administered topiramate intraperitoneally at doses of 25, 50 and 100 mg/kg, respectively, 1 h before raising the flap and once daily for 7 consecutive days after the initial surgical procedure. Control rats received vehicle according to the same schedule. On postoperative day 7 the flap necrotic area was measured, and tissue samples were stained with hematoxylin and eosin for histological analysis. Furthermore, the oxidative stress in flap tissue was assessed by measuring the activity of superoxide dismutase (SOD), glutathione (GSH) level and the content of malondialdehyde (MDA). Treating animals with 50 and 100 mg/kg topiramate significantly decreased the necrotic flap areas as compared to the control group. Histological studies demonstrated that in intermediate and high dose topiramate groups the inflammatory cell numbers were attenuated and microvessel development were markedly increased. Furthermore, the MDA contents were significantly reduced and GSH levels were significantly increased in these groups as compared to the control group. However, the SOD activity was increased significantly only in high-dose group as compared to the control group. These findings indicated that topiramate in doses of 50 and 100 mg/kg increases random skin flap survival. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Gluteal Fold V-Y Advancement Flap for Genital Reconstruction following Radical Vulvectomy with Bilateral Inguinofemoral Lymphadenectomy in Vulvar Cancer: A Case Report

Background: Vulvar cancer is a rare malignancy representing about 4% of all genital cancers in women. Historically, the gold standard for treatment of squamous cell carcinoma of the vulva was en bloc radical vulvectomy with bilateral inguinofemoral lymphadenectomy. For the reconstruction the options are primary closure, skin grafts, or local and distant flaps. In this case we used the gluteal fold fasciocutaneous V-Y advancement flap that is sensate and thin with a reliable blood supply, can be advanced easily, and can be performed in a single-stage procedure. Care Report: We present a clinical case of an 82- year old female patient who had an exophytic vulvar lesion, which grew progressively with the histopathologic diagnosis of invasive vulvar squamous cell carcinoma. It was decided to perform radical vulvectomy with right unilateral lymphadenectomy and reconstruction with Gluteal Fold V-Y Advancement Flap. During the post-surgical period it recurred with wound dehiscence and finally skin necrosis developed in the area of the left thigh. Surgical debridement, escharectomy, harvesting and application of skin graft, and closure of the femoral hernia with omentum patch were performed with no associated complications. Follow-up was carried out during the next 3 months after surgery. She presented adequate evolution of the flap and left thigh area. Conclusions: The Gluteal Fold V-Y Advancement Flap is an excellent option for the reconstruction of the vulvovaginoperineal area after a radical vulvectomy. It provides us with a good prognosis and quality of life for the patient. Article Details Issue

Post-treatment with metformin improves random skin flap survival through promoting angiogenesis in rats.

Skin flap necrosis has been remained as an unsolved problem in plastic and reconstructive surgeries. Here, we explored the effects of metformin post-treatment on random skin flap survival in rats. An 8.00 × 2.00 cm dorsal skin flap was created in 24 rats and they were then divided into three groups (n = 8) including Control, metformin (Met) 50.00 mg kg-1 and Met 100 mg kg-1. All animals were administrated orally until seven days after flap surgery. Flap survival, the number of blood vessels and mast cells in the flap tissues were analyzed. Vascular endothelial growth factor (VEGF) expression levels in flap tissues was also determined using immunohistochemical methods. The percentage of survival area in Met 50.00 mg kg-1 and Met 100 mg kg-1 groups were significantly higher compared to control. The blood vessel density and the VEGF positive cells in the viable areas of flaps showed a significant increase in Met 50.00 mg kg-1 group compared to control group. The results of this study suggested that treatment with metformin, especially with low dose following skin flap surgery was effective in improving the flap survival and increasing the neovascularization in the flaps tissues of rats.

Comparison of Flap and Bank-Angle Steering for Mars Entry

Previous Mars entry, descent, and landing systems have used bank-angle steering during the hypersonic phase of entry to control range. An alternate solution for hypersonic steering is a set of independently articulated aerodynamic flaps. Deflecting these flaps results in trim at nonzero angles of attack and sideslip angles, enabling the vehicle to generate lift in arbitrary directions. This study compares current state-of-the-art bank-angle steering to flap-based steering across several metrics, including aerodynamic control authority, range capability, and response time. The effective bank angle and effective lift-to-drag ratio are developed to compare the control authority between flap and bank-angle steering systems. The shape of the nonaxisymmetric control authority depends on the flap placement, area, and number of flaps; however, flap-based steering systems likely require a mechanism for roll or bank in order to have a uniform control authority. Aerodynamic control authority is then mapped to a range capability. Flap steering vehicles exhibit range capabilities with markedly different shapes than bank-angle steering vehicles with equivalent maximum hypersonic lift-to-drag ratios. Flap steering vehicles are found to be able to rotate directly between angular positions and have both a more uniform and faster response time than bank-angle steering vehicles.

Melatonin Improved the Survival of Multi-Territory Perforator Flaps by Promoting Angiogenesis and Inhibiting Apoptosis via the NRF2/FUNDC1 Axis.

Background: Multi-territory perforator flaps are a reconstructive measure for repairing large soft tissue defects caused by tumors or trauma. However, the use of these flaps in clinical practice has been restricted due to the uncertain blood supply. Therefore, promoting the survival of the multi-territory perforator flap is critical for clinical repair and reconstruction. In our study, we explored the effects of melatonin (MLT) on multi-territory perforator flaps and the possible molecular mechanisms. Materials and Methods: Seventy-two Sprague–Dawley rats (250–300 g) were randomly divided into 3 groups (n = 24): Control, MLT and MLT + ML385 groups. First, we assessed the survival area of the flap, followed by the micro-vessel density and CD31-positive vessel expression. Apoptosis of the skin flap under immunofluorescence and expression of the apoptosis-related proteins Bcl-2, Bax and Caspase3 were measured. Additionally, angiogenesis of the skin flaps was shown by angiography, and NRF2 and FUNDC1 mRNA and protein expression was detected by real-time PCR and western blotting. Results: The results showed that MLT increased the survival area of the multi-territory perforator flap, which was related to increased angiogenesis and decreased apoptosis. We also found that mRNA and protein of NRF2 and FUNDC1 levels were significantly increased after MLT treatment, and an NRF2 inhibitor reversed the ability of MLT to enhance multi-territory perforator flap survival, promote angiogenesis and inhibit apoptosis and reduced FUNDC1 protein expression. Conclusion: MLT promoted angiogenesis and inhibited apoptosis to promote the survival of multi-territory perforator flaps, which may be regulated via the NRF2/FUNDC1 axis.