Flap Expansion Research Articles

Concentrated growth factor intradermal injection assisted super-thin flap expansion for repairing skin defects: A randomized, single blinded, split-site study.

The super-thin skin flap formed by skin and soft tissue expansion has large area and good ductility, so it can be used to repair skin defects. However, because the flap is thin, the blood flow in the dermis of the super-thin expanded flap is weakened, and flap rupture and necrosis after secondary flap transfer may occur. To compare the skin thickness difference between the expanded ultrathin flaps injected with concentrated growth factor (CGF) and the blank group or saline group. From June 2021 to December 2023, 10 patients (44 sites) with large-area scars or skin tumors were treated, and a single center half randomized controlled trial was conducted. The test site of expander implantation was divided into three groups: intradermal injection of CGF group, normal saline group and blank group. The same amount of expansion was performed every 1-2 weeks, and CGF or normal saline was injected into the dermis every 4 weeks, a total of three times. After 2-3 months of expansion, color Doppler ultrasound was used to measure the skin thickness of each group. Compared with the blank group, the skin thickness of CGF group was 1.75 ± 0.08 mm, and that of BLA blank group was 1.42 ± 0.07 mm, with statistically significant difference (p < 0.0001); In the other group, compared with the saline group, the skin thickness of the CGF group was 1.54 ± 0.08 mm, and the average skin thickness of the saline group was 1.40 ± 0.08 mm, with significant difference between the two groups (p = 0.0067). CGF intradermal injection can increase the skin thickness of super-thin skin flap in the process of soft tissue expansion, which is a safe and effective auxiliary method of skin expansion.

Finding Perforator "Freeway" for Design Optimization of Expanded Flaps by Indocyanine Green Angiography.

Indocyanine green angiography (ICGA) is a useful tool for the visual assessment of superficial blood flow. Herein, we used ICGA to visualize perforator branches and linking vessels to provide a road map for flap design of an expanded flap. Twenty-eight expansions were planned to use back-cut technique in 26 patients. ICGA was used to visualize perforator branching pattern with the linking vessels and the venous network in the expanded flap before expander explantation. The appropriate perforator was selected, and the flap was designed following the axiality of its branch linked by true anastomoses. The vein running closely was chosen as the axial vein. The back cut was designed to avoid transection of the axial artery and vein. Patient demographics, defect characteristics, and reconstructive outcomes were assessed. ICGA clearly visualized the perforator branches and the linking vessels in the expanded flap at the head and neck, trunk, and extremity. The back-cut flap containing the axial artery and vein was raised successfully in 27 expansions. The arterial perforator and superficial vein separated greatly and resulted in design modification from back-cut to advancement flap in one expansion. All expanded flaps met the reconstructive needs and exhibited complete survival. ICGA allowed the visualization of the preoperative topography of the vascular network in the expanded flap and helped surgeons locate the vascular axis and perform an appropriate back-cut design for efficient and safe flap transfer.

Dynamic alterations in M2 macrophage subtypes enhance flap expansion efficiency and tissue regeneration.

Dilatation of soft skin tissue is a common surgical procedure in plastic surgery. M2 macrophages play a critical role in reducing inflammation, promoting epithelial and vascular endothelial cell proliferation, enhancing collagen synthesis in fibroblasts, and orchestrating extracellular matrix remodelling by promoting angiogenesis, epithelialisation, and fibrosis. Macrophages improve flap survival by promoting microangiogenesis and collagen remodelling. However, the role of macrophages in flap expansion has not yet been investigated. Improving the expansion efficiency of dilatation flaps and promoting flap vascularisation are the pressing problems in the fields of plastic and reconstruction surgery. In the present study, we used a mouse model to assess the effects of macrophage activation on skin expansion, thickness, ultrastructure, intradermal angiogenesis, and collagen and cytokine levels. Our findings revealed dynamic changes in the macrophage content and subtypes within the expansion flaps. The enrichment of M2 macrophages significantly enhanced the efficiency of flap expansion, vascularisation, and collagen synthesis. Our findings underline the pivotal role of M2 macrophages in tissue regeneration at the molecular and biochemical levels. These findings provide a basis for improving flap expansion efficiency using M2 macrophages.

Clinical application of retrosigmoid approach for BONEBRIDGE implantation after auricle reconstruction using expanded postauricular flap

Objective: To explore the safety and reliability of retrosigmoid approach BONEBRIDGE implantation in patients with auricle reconstruction using skin expansion flap. Methods: A retrospective analysis was conducted on 43 congenital aural atresia cases (43 ears) who underwent BONEBRIDGE implantation from September 2019 to January 2023 in Beijing Tongren Hospital. 30 males and 13 females were included in this work. The implantation age was 9-36 years old (median age=10 y/o). All cases underwent auricle reconstruction surgery using the posterior ear flap expansion method, with 36 cases using the single expanded postauricular flap method and 7 cases using two-flap method. BONEBRIDGE implant surgery was performed during the third stage of auricle reconstruction or after all stages. The hearing improvements were evaluated by comparing the changes in pure tone hearing threshold and speech recognition rate of patients before and after BONEBRIDGE implantation. Routine follow-up was conducted to observe the hearing results and complications. SPSS 14.0 software was applied for data statistical analysis. Results: All 43 patients healed well and had no surgical complications when discharge. The average bone conduction hearing threshold after surgery was (8.2±6.6) dBHL, and there was no statistically significant difference compared to the preoperative [(8.1±5.7) dBHL] (P=0.95). After surgery, the threshold of hearing assistance with power on was significantly lower than that without hearing assistance [(32.8±4.6) dBHL vs (60.5±5.5) dBHL], and the difference was statistically significant (P<0.001). The speech recognition rate of monosyllable words, disyllabic words and short sentences in quiet environment increased to 72%, 84%, and 98% respectively. The differences were statistically significant (P<0.001). The speech recognition rate of monosyllabic words, disyllabic words, and short sentences in noise environment was significantly increased by 70%, 80%, and 92% respectively (P<0.001). After a follow-up of 4 to 47 months (median=24 months), the hearing results were stable and the aesthetic outcomes were satisfying. One patient had delayed hematoma around coil of the implant. After aspiration and compressed dressing for one week, hematoma was not recurrent. Conclusion: For patients after auricle reconstruction using expanded postauricular flap, the preference of retrosigmoid approach is a good choice in terms of safety and reliability of operation, as well as aesthetic appearance.

Closure of Giant Dorsal Lumbosacral Myelomeningocele in Children Using Double Expanded Flaps: A Case Report and Literature Review.

Myelomeningocele (MMC) is the most common neural tube defect that can occur due to neural tube's failure to fuse properly during embryonic life. To prevent this, expanded flaps can be used for closure of large MMCs. A 4-year and 6-month girl was diagnosed with multiple congenital anomalies including hydrocephalus, dorsal lumbosacral MMC, and congenital tethered cord syndrome. Preoperative evaluation showed no lower limb movements and the size of the sacrococcygeal region was about 10cm × 8cm × 15cm mass, prominent thoracic kyphosis, and no obvious urogenital or limb anomalies. The large dorsal lumbosacral MMC was treated with a double expanded flap to reconstruct, the soft tissue defect following the neurosurgical reconstruction. The expanded flap was deemed as viable as all wounds were healed without any complications, such as dehiscence, leakage of cerebrospinal fluid, or infection. The technique described in the case report offers an effective method of closure. This flap can be an effective method for reconstruction of large dorsal lumbosacral MMC defects that might improve outcomes and minimize complications. It also ensures minimal wound tension and breakdown.

Hypoxia-induced CCL2/CCR2 axis in adipose-derived stem cells (ADSCs) promotes angiogenesis by human dermal microvascular endothelial cells (HDMECs) in flap tissues.

Flap expansion has become an important method widely used in wound repair and organ reconstruction. However, distal skin flap ischemic necrosis remains a problematic complication. In this study, integrative bioinformatics analyses indicated the upregulation of C-C motif chemokine ligand 2 (CCL2) and C-C motif chemokine receptor 2 (CCR2) in reperfusion-exposed skin flap tissues. In adipose-derived stem cells (ADSCs, CD90-positive, CD29-positive, CD34-negative, and CD106-negative) exposed to hypoxia, HIF-1α and CCL2 levels were significantly elevated. Conditioned medium (CM) from hypoxia-stimulated ADSCs promoted HDMEC proliferation, migration, and tube formation, partially inhibited by sh-CCL2-induced CCL2 knockdown or neutralized antibody-induced CCL2 depletion in ADSCs. Consistently, CCL2, CCR2, TNF-α, TLR2, and TLR4 protein levels in HDMECs were significantly increased by hypoxia-treated ADSCs CM, and partially decreased by sh-CCL2-induced CCL2 knockdown or neutralizing antibody-induced CCL2 knockdown in ADSCs. In the flap expansion model, ADSCs transplantation significantly improved flap survival and angiogenesis by endothelial cells in flap tissues, whereas CCL2 knockdown in ADSCs partially eliminated the improvement by ADSCs transplantation; overexpression of CCL2 in ADSCs further promoted the effects of ADSCs transplantation on skin flap. In conclusion, the CCL2/CCR2 axis in ADSCs could be induced by hypoxia, promoting HDMEC proliferation, migration, and tube formation and improving flap survival and angiogenesis in flap tissues.

Testing the circulation of expanded flaps-prevention of necrosis of expanded flaps (a clinic study).

Expanded flaps are commonly used in plastic surgery. Although expanded flaps are more resistant to hypoxia than unexpanded flaps, flap necrosis can sometimes occur, particularly with skin incisions of regular proportion. Distal skin necrosis of the expansion flap can be avoided by careful design; however, the utilization rate of the expansion flap decreases. Consequently, successfully avoiding distal skin flap necrosis remains a challenge. In this study, we designed a device for testing the circulation of the expanded flap that can decrease the risk of expanded flap necrosis, thus maximizing the use of an expanded flap. A total of 128 patients who underwent surgical repair between 2011 and 2019 and were retrospectively examined with the device for testing the circulation of the expanded flap were included in the study. The procedure included (1) making a device for testing the circulation, (2) implanting a skin expander, (3) injecting normal saline into the skin expander, (4) testing the circulation of the expanded flap, and (5) transferring the expanded flap to repair the defect. One hundred forty-eight expanded flaps were implanted in 128 patients. The expanded flap that was transferred to repair the defect had no necrosis or infection. None of the expanded flaps with separated blood supply, which could be observed during operations, revealed complications. The survival rates of the expanded flap were increased by testing the circulation of the expanded flap. Expanded flaps designed by this method showed no swelling or paleness and no obvious temperature changes. In addition, the length-to-width ratio could be extended to 3:1. Our proposed method resulted in an effective surgical procedure for the repair of tissue defects. This approach could effectively change the direction of the blood vessel of the expanded skin flap and prevent necrosis of the expanded flap, thus representing a practical way to increase the use of expanded flaps and the flap survival rate, making the whole expanded flap transfer procedure more convenient.

Facial Defects With Infraorbital and Zygomatic Area Reconstruction Using an Expanded Flap Based on the Orbicularis Oculi Muscle: A Long-Term Follow-up.

Reconstruction of facial soft-tissue defects may pose a dilemma for plastic surgeons, as the flaps must be reliable to obtain a natural appearance while minimizing donor site morbidities. This clinical study describes a reconstructive method for infraorbital and zygomatic defects using a pre-expanded rotation flap based on the orbicularis oculi muscle (OOM). The surgeries were subdivided into 2 stages. In the first stage of the operation, a 100 to 200mL expander was placed underneath the temporal area through a hairline incision. In the second stage, after adequate inflation of the expander, the pre-expanded rotation flap based on the OOM of the lower eyelid was raised from lateral to medial to cover the facial defects. In this single-center study from February 2010 to February 2017, 16 patients underwent facial defect reconstruction using the pre-expanded flap based on the OOM. All of the defects were located at the infraorbital and zygomatic regions, and their sizes ranged from 3.0 4.0 to 7.0 14.0cm. The causes of these defects included postburn scars (37.5%), melanocytic nevus (50%), and hemangiomas (12.5%). In all cases, good coverage was provided for the defects that were in the medial cheek or lower eyelids. There were no flap losses of any kind. There were no major complications, and all minor incidences were treated by minimal procedures. The patients were followed up after surgery, with the follow up ranging from 6 months to 108 months. The follow-up data included postoperative consultations, the defect size, the need for further procedures and the degree of satisfaction. The pre-expanded rotation flaps in the lateral facial area based on the OOM can ideally and safely be applied for facial defect reconstruction owing to their reliable blood supply and excellent texture match.

Glutodon gen. nov. (Hymenoptera, Bethylidae), a flap-metasomed Pristocerinae from Madagascar.

Here we describe the flat wasp genus Glutodon gen. nov., and its single species G. mikeaensis sp. nov. from Madagascar. The males of this genus are easily recognized among the other genera of Pristocerinae by having the metasoma with a conical flap expansion on the sternum VIII and the hypopygium with the anterolateral apodeme very thick along its length with a very gibbous tip, both conditions unique in Bethylidae. Glutodon gen. nov. is the sixth genus of flat wasps endemic of Madagascar, and the 30th of Pristocerinae.

Reconstruction of a massive facial defect with the pre-expanded free anterolateral thigh flap: A case report.

Introduction and importanceMassive facial defects remain a reconstructive challenge because of the region's unique character and the limitation of a well-matched donor site. Pre-expanded free anterolateral thigh (ALT) flap provides a good alternative for reconstructing massive skin and soft tissue defects.Case presentationA 21-year-old male patient presented to our department with a massive right facial degloving wound caused by a sharp edged-weapon attack. The patient left the hospital after 3 weeks of wound care, and only came back to us after 2 months with large defects at the nasal, cheek, and upper and lower right lip regions. The procedure of ALT flap expansion surgery was performed for 2 months. The pre-expanded ALT flap was used for reconstruction of the patient's facial defects. Two-year follow-up showed that the flap at the reconstructed area resembled the contour of the nasal tip, facial skin color similarities in the cheeks and lips, and the patient's mouth had normal function.Clinical discussionThe combined pre-expanded and composite ALT free flap techniques allow simultaneous reconstruction of many different anatomic units. Flap debulking helps to improve the nasal contour from the original defect. The lip separation technique and flap debulking procedure help enhance aesthetic reconstructive outcomes of the skin flap.ConclusionThe surgical reconstruction using a pre-expanded ALT free flap for the patient with a massive facial defect was safe. In particular, sufficient skin and soft tissue ensured facial aesthetics and oral function for the patient when using this method.

Resurfacing in Facial Burn Sequelae Using Parascapular Free Flap: A Long-Term Experience.

It is difficult to treat large postburn sequelae (scars and defects) over the face. Available methods include skin grafts, local flaps, tissue expansion, and free flaps. These surgical options should be chosen wisely, depending on individual patient requirements and the area involved. In patients with large postburn scars and defects in which the surrounding tissue is also involved, use of free tissue transfer is extremely useful. A retrospective analysis was done between 2011 and 2019 of 52 cases with extensive facial burn deformities in whom secondary reconstruction was done with free parascapular flap cover in our department. Outcome was assessed by a direct questionnaire. There was no complete flap loss in the series. Two cases were re-explored for venous insufficiency and suffered partial marginal necrosis. Twenty patients had to undergo further debulking procedure. Forty-seven patients were satisfied by the final outcome. Postburn facial deformities are difficult to treat; in many cases, there are no local options, and tissue from different regions is to be used for reconstruction. Free parascapular flaps can be used as an effective method in such cases with a high level of patient satisfaction.

Photoacoustic microscopy: a novel approach for studying perforator skin flap in a mouse model.

A comprehensive understanding of cutaneous microvessels is key to the design and use of the perforator skin flap. Compared with the various imaging technologies that have been applied in the clinical practice of the perforator skin flap, photoacoustic microscopy (PAM) is a very promising noninvasive imaging modality with high resolution and deep penetration in biological tissues. PAM was employed to explore its multiple applications in a perforator skin flap. The following experiments were then conducted in 3 parts. In part 1, 7 mice were used to obtain the preoperative perforator mapping on the mouse back. In parts 2 and 3, 7 mice were used to design and harvest the multiterritory perforator flap. The status of the flap and the morphological changes of choke vessels were subsequently observed by PAM at several time points. The results showed that PAM could visualize and assess the vascular physiological and pathological conditions of the skin tissue in real time in vivo with high spatial and temporal resolution. It could also provide preoperative perforator mapping, including the total number of perforators, localization, vascular territories, and diameter. Furthermore, it could offer a quantitative, objective method to monitor the status of the perforator skin flap, and was capable of noninvasive characterization of the changes of choke vessels that play an important role in multiterritory perforator skin flap expansion and survival. PAM has great potential to be an effective and precise quantitative imaging tool for perforator skin flap research, such in as flap design, monitoring, and choke vessel observation.

A Pharyngoplasty with a Dorsal Palatal Flap Expansion: The Evaluation of a Modified Surgical Treatment Method for Obstructive Sleep Apnea Syndrome-A Preliminary Report.

Surgical techniques for obstructive sleep apnea syndrome (OSAS) constantly evolve. This study aims to assess the effectiveness and safety of a new surgical approach for an OSAS pharyngoplasty with a dorsal palatal flap expansion (PDPFEx). A total of 21 participants (mean age 49.9; mean BMI 32.5) underwent a type III sleep study, an endoscopy of the upper airways, a filled medical history, a visual analog scale for snoring loudness, an Epworth Sleepiness Scale, and a Short Form Health Survey-36 questionnaire. A follow-up re-evaluation was performed 11 ± 4.9 months post-operatively. The study group (4 with moderate, 17 with severe OSAS) showed an improvement in all measured sleep study characteristics (p < 0.05), apnea-hypopnea index (pre-median 45.7 to 29.3 post-operatively, p = 0.009, r = 0.394), oxygen desaturation index (pre-median 47.7 and 23.3 post-operatively, p = 0.0005, r = 0.812), mean oxygen saturation (median 92% pre-operatively and median 94% post-operatively, p = 0.0002, r = 0.812), lowest oxygen saturation (p = 0.0001, r = 0.540) and time of sleep spent with blood oxygen saturation less than 90% (p = 0.0001, r = 0.485). The most commonly reported complications were throat dryness (11 patients) and minor difficulties in swallowing (5 patients transient, 3 patients constant). We conclude that a PDPFEx is a promising new surgical method; however, further controlled studies are needed to demonstrate its safety and efficacy for OSAS treatment in adults.

Clinical effects of expanded flap in repairing the wounds with exposed titanium mesh after cranioplasty with titanium mesh

Objective: To explore the clinical effects of expanded flap made by skin and soft tissue expander (hereinafter referred to as expander) in repairing the wounds with exposed titanium mesh after cranioplasty with titanium mesh. Methods: A retrospective observational study was conducted. From April 2015 to October 2019, 13 patients with wounds with exposed titanium mesh after cranioplasty with titanium mesh were admitted to the First Affiliated Hospital of Air Force Medical University, including 10 males and 3 females, aged 18 to 70 years. Exposure of titanium mesh occurred 3 months to 4 years after cranioplasty with titanium mesh. The wound area of exposed titanium mesh ranged from 1.5 cm×0.6 cm to 6.3 cm×6.0 cm. In the first stage, one or two square expanders with rated capacity of 50-200 mL were placed under the normal scalp 1 cm away from the edge of the wound surface of exposed titanium mesh. The water injection time was 2 to 3 months with the total water injection volume being 1.6 to 2.0 times of the rated capacity of expander. In the second stage, the expander was removed and the expanded flap (size ranging from 4.1 cm×1.8 cm to 9.1 cm×7.9 cm) was transferred to repair the wound of exposed titanium mesh. The placement site of the expander, the transfer form of the expanded flap, the postoperative wound healing of the titanium mesh exposed site, and the survival of expanded flap were recorded. The scar of the head incision and the appearance of head were followed up. Results: Among the patients in this group, the expanders of 7 were placed in the temporal region, while the other 6 were placed at the top. The 11 patients were treated with advanced expanded flap, while the other 2 patients were treated with pedicled expanded flap. The head wounds of patients in this group successfully healed with retaining of the titanium mesh. The wound was healed after dressing change in 1 patient with necrosis at the tip of the expanded flap. The expanded flaps of 12 patients survived after transfer. Patients in this group were followed up for 12 months after surgery, the exposed titanium meshes were retained, the incisions healed well with the scars concealed, the hair on the scalp grew well, and the appearance of head was comparatively good. Conclusions: Using expanded flap in the repair of the wounds with exposed titanium mesh after cranioplasty with titanium mesh can effectively cover the wound and retain the titanium mesh, achieving good function and appearance.

Repair Exposure of the Postauricular Tissue Expander Using the Modified Brent Method: A 7-Year Experience.

Ear reconstruction is a challenging surgery for the complicated conditions in patients with microtia. The tissue expansion techniques were necessary and relatively safe for patients with insufficient soft tissue. However, complications such as necrosis of expanded flap and exposure of tissue expander limited the popularization of this method. This study described the use of modified Brent method to handle the exposure of the postauricular tissue expander. From January 2013 to December 2019, 27 ear reconstruction patients with trauma or necrosis on an expanded skin flap and subsequent exposure of tissue expander were treated with modified Brent method, which consisted of 3 stages: removal of the expander, tension-free closure of wound, and framework fabrication; elevation of reconstructed ear; lobule rotation; and minor modification. Fifty-six percent of exposures occurred in the lower pole of the tissue expander. Exposure usually occurred 54.5 days after implantation. The majority of reconstructed ears had a satisfactory appearance and showed relatively stable outcomes. Only one case of cartilage exposure required revision surgery and was repaired by the temporoparietal fascia. With reasonable distribution of expanded flap, prolonged interval, and sutures under tension-free conditions, complications like the occurrence of trauma or necrosis-induced exposure of tissue expander can be repaired efficiently by a staging modified Brent method.

Prefabricated Expanded Flap Combined With Expanded Scalp Flap for Total Face Resurfacing.

Reconstruction of total facial deformities and defects has been a major challenge of reconstructive surgery. Allotransplantation is limited by the number of donors and the need for life-long immunosuppression. Autotransplantation, where multiple autogenous tissue grafts from various donor sites are used to repair facial defects, inevitably leaves conspicuous patchwork scars. A prefabricated monoblock flap, although the preferred treatment modality, is limited by insufficient blood supply and the large size of the flap. In the Journal of Craniofacial Surgery (2014;25:21-25), Li et al applied the technique of flap prefabrication and stem cell-assisted tissue expansion to reconstruct total facial injuries, but the operations were complicated and the final expanded flap area was also uncertain. This article introduces an approach to reconstruct total facial injuries with a prefabricated expanded thoracic flap combined with an expanded scalp flap (called combined flaps), which not only solves the limitations of blood supply and expanded volume but also reduces patchwork scars. The approach is a simple, feasible, and effective surgical method for total face resurfacing.

Incision and flap design during total auricular reconstruction using a 2-stage strategy.

BackgroundTotal auricular reconstruction is a challenge for plastic surgeons. Expanded flap method and Nagata’s method with autologous costal cartilage are two leading techniques for ear reconstruction. And a two-stage strategy of expanded flap method received attention. In the present study, we report the incision and flap design of this strategy.MethodsIn the first stage, an 80 mL kidney-shaped expander was inserted in the mastoid region with the larger pole superiorly. The expander pocket was dissected subcutaneously in the scalp area and subfascially in the lower third region. In the second stage, the expander was removed from a Y-shaped lobule incision on the remanent ear. Then the remnant ear was separated into three flaps: the posterior skin flap, anterior skin flap, and lobule flap. When the framework was fabricated, the base frame and the underlying pad, which enhanced the projection, were fixed together as a whole to provide a more prominent appearance. The framework was totally wrapped into the expanded single flap without free skin grafting. Lobule transposition and tragus construction were performed simultaneously instead of a third-stage surgery. The recipient bed of rotated lobule was resected only to the epidermal layer and the subcutaneous layer was preserved to avoid central necrosis.ResultsA total of 21 patients received this strategy to reconstruct ear. With 3 months to 1.5 years of follow-up, 19 patients (90.5%) were satisfied with the reconstructed ears. 3 patients (14.3%) required further modification of reconstructed ear. No serious complications occurred during the procedures.ConclusionsWith a Y-shaped incision, three-flap design of remanent ear and lobule rotation to an epidermal-removal area, tissue expander removal and modification of remanent ear can be performed effectively to avoid necrosis and an extra operation.

Clinical effect of pre-expanded deltopectoral flap in the repair of faciocervical lesion and defect

Objective: To explore the clinical effect of pre-expanded deltopectoral flap in the repair of faciocervical lesion and defect. Methods: From July 2004 to August 2018, 355 patients with faciocervical lesion and defect were admitted to the First Affiliated Hospital of Air Force Medical University, including 200 males and 155 females aged 4 to 48 years with major conditions including thermal burn scars, and type Ⅲ and Ⅳ facial-cervical deformities. During the stage Ⅰ skin soft tissue expander implantation surgery, according to the size and location of lesion and defect, expanders with appropriate volume were placed to expand the deltopectoral area. During the stage Ⅱ flap pedicled transposition surgery, after the expander was expanded to the desired volume, the impairment tissue was removed, the flap was designed according to the size of the defect (the unilateral defect area was 7 cm×5 cm to 17 cm×16 cm) and pedicled transposition was carried out. The incision in the chest donor area was directly sutured and closed. After the flap survived, stage Ⅲ flap delay and pedicle division surgery was carried out. The area of one single flap was 8 cm×5 cm to 20 cm×18 cm. The numbers of flaps and expanders, rated volume and expansion of expander, the intervals between surgeries in each stage, flap survival, postoperative complications in surgeries in each stage, and follow-up were recorded and analyzed. Results: A total of 460 pre-expanded deltopectoral flaps were used, including 250 unilateral flaps and 105 bilateral flaps. Totally 460 expanders were used in this group of patients. The rated volume was mostly 500 mL (163 expanders) and 600 mL (142 expanders). The expansion multiple of the expander was (1.14±0.19) times of the rated volume. The flap expansion time of the patients was (96±30) d, the pedicle time was (32±8) d, and the delay time was (7.5±1.6) d. The postoperative complications of patients mainly included infection (29 patients), expander exposure (18 patients), and hematoma (10 patients). During the follow-up of 6 to 120 months, the elasticity, texture, and color of the flaps of patients were similar to the surrounding tissue of the recipient area, and the face and neck were symmetrical, not bloated. Conclusions: The deltopectoral flap obtained by overexpansion has a larger area and a thinner thickness, and the elasticity, texture, and color are similar to the surrounding tissue of the recipient area. After transfer, a stable appearance of the face and neck can be obtained. The main complications are infection and expander exposure, most of which occurred after stage Ⅰ skin soft tissue expander implantation surgery.

Pediatric upper extremity surgery: BMI is not associated with increased complication rate

While the effect of body mass index (BMI) on upper extremity surgical outcomes has been investigated in adults, limited data exists in the pediatric population. We sought to identify the complication rate in pediatric upper extremity surgery and determine the effect of BMI on complication rates. Subjects were pediatric patients that underwent reconstructive surgery between 2005 and 2011. BMI percentiles were classified as: underweight (< 5th percentile), healthy weight (5th–< 85th percentile), overweight (85th–< 95th percentile), or obese (≥ 95th percentile). Postoperative complications included wound infection, partial wound dehiscence, hematoma/seroma formation, tissue expander exposure, flap coverage, short- or long-term dressing, observation, hospital admission, reoperation, and death. Complication rates were compared using Chi-square analysis. We identified 182 patients who underwent 269 operations that comprised 805 procedures. Subjects included 88 females (48.35%) and 94 males (51.65%), with an average age of 13.02 years. Average number of procedures per operation was 2.99. Of the 805 procedures, 47 (5.84%) included at least one postoperative complication. The most common complication was partial wound dehiscence (2.98%), followed by need for short term dressing (1.86%) and observation of tissue expander (1.37%). Only 9 procedures (1.12%) required reoperation. BMI was not a predictor of postoperative complication rates (p = 0.669). In our pediatric patient population, BMI was not a significant risk factor for postoperative complications. Our data suggests that plastic surgery of the upper extremity is safe regardless of BMI with low complication rates and no reported mortality within in our study population. Level of evidence: Level IV, risk/prognostic study

The Use of Indocyanine Green Angiography to Predict Expanded Flap Viability

The Use of Indocyanine Green Angiography to Predict Expanded Flap Viability