Lateral Flap Research Articles

Male-to-Female (MtoF) gender affirming surgery: Modified surgical approach for the glans reconfiguration in the neoclitoris (M-shape neoclitorolabioplasty)

The aim of this article is to describe our modified surgical technique for the reconfiguration of the glans in the clitoris and the labia minora, known as the "M-shape neoclitorolabioplasty". The glans with all its neurovascular bundle is isolated from the corpora cavernosa, incised in Y-shape mode and spread in order to obtain an M-shape glandular flap. The "belly" of the M-shape glans will constitute the triangular neoclitoris meanwhile the lateral flaps will constitute the labia minora. The inferior apex of the neoclitoris is fixed to the superior apex of the previously spatulated urethra. The two glans flaps are incised transversally to increase their length and sutured to the sides of the spatulated urethra forming the labia minora. Our technique permits to create an aesthetically pleasing neovagina preserving all the glandular erogenous sensitivity. 94 patients have been treated with our modified technique of male-to-female (MtoF) gender affirming surgery. At median follow-up of 27.57 months, 81 (86.1%) patients reported vaginal intercourse and 78 (82.9%) patients referred presence of erogenous sensitivity during dilatations, intercourse or masturbations. All the glandular tissue is preserved and reconfigured forming the neoclitoris and the labia minora. The M-shape reconfiguration permit to create an aesthetically pleasant neoclitoris. This technique could be applied safely and easily to patients undergoing gender affirming surgery, allowing the creation of a neovagina with the best possible erogenous sensitivity without losing aesthetical results.

The application of micro-dissected polyfoliate anterolateral thigh perforator flap in repair of complex wound in extremities

Objective To investigate the design, incisional method and clinical experiences of using the microdissected polyfoliate anterolateral thigh perforator flap to repair of complex soft tissue defect in extremities. Methods From June, 2017 to September, 2018, 12 cases of different kinds of complex soft tissue defect in extremities were repaired by micro-dissected free polyfoliate anterolateral thigh perforator flap. Each flap was divided into two cutaneous perforators to give two separate flap with a common vascular supply. The flaps were cut from the superficial layer of the deep cervical fesciae and without fascia lata. The donor sites were treated by subcutaneous cosmetic suture. Patients were followed-up by outpatient service, telephone and WeChat video to observe and record the flap’s appearance, sensory recovery, extremities function and the scars of the donor site to evaluate its clinical efficacy. Results All flaps survived without vascular crisis happened except one-leaf necrosis occurred, which healed with local flap transferring. The donor sites remained linear scars. The mean flap thickness of this group after micro-dissection was (4.5±0.5) mm. All the patients were followed-up for 5-15 months. The 2 point discrimination ranged between 0.5-2.0 cm. Sensory restoration ranking was S3-S3+. The range of montion of wrist joint was 65°-90°, and that of ankle joint was 40°-60°. Conclusion The micro-dissected polyfoliate anterolateral thigh perforator flap is an ideal method for complex and irregular multiple sites soft tissue defect in extremities as it can keep good economic benefit and minimal damage to the donor site. Key words: Polyfoliate, perforator flap; Anterior lateral thigh flap; Flap thinning technique; Extremities; Microsurgical technique

New species of Anacanthorus (Dactylogyridae: Anacanthorinae) from the gills of Hoplerythrinus unitaeniatus and Erythrinus erythrinus (Characiformes:Erythrinidae) of the coastal drainage in the Eastern Amazon, Brazil.

Species of Anacanthorus are described from the gills of Hoplerythrinus unitaeniatus and Erythrinus erythrinus of drainage systems in the Northeastern Pará State, Brazil. Anacanthorus scyphophallus sp. n. has a male copulatory organ (MCO) with two small flaps in the distal portion; hooks with proximal shank dilatation comprising ½ of the shank length. Anacanthorus ataidei sp. n. has an elongated MCO, with ribbon-like ornaments; hooks without proximal shank dilatation. Anacanthorus siphonocommus sp. n. has an MCO with aculeiform ornaments in the distal portion; hooks with proximal dilatation in the shank comprising ½ of the shank length. Anacanthorus maratininguensis sp. n. has an MCO with a small projection in the form of a hook in the distal region; hooks with proximal dilatation comprising ½ of the shank length. Anacanthorus lacinimentulatus sp. n. has an MCO with extrovert flap skirting its distal region; shank of hooks with proximal dilatation comprising ½ of the total shank length. Anacanthorus cururutuiensis sp. n. presents an MCO with flexed lateral flap in the distal region; hooks with proximal dilatation in the shank comprising ¼ of the shank length. Anacanthorus circumspatulatus sp. n. has an MCO with ornaments in the form of pointed and interleaved blades; hooks with proximal shank dilatation comprising approximately ½ of the shank length. Anacanthorus acrophallus sp. n. has MCO with a small pointed sinistral flap; hooks with proximal dilatation in the shank comprising 1/3 of the shank length. The host-parasite diversity scenario and specificity of Anacanthorus species regarding their characiform hosts are also discussed in this study.

Choosing the right rectangular expander and maximising the benefits from expanded tissue.

Tissue expanders are widely used in the reconstruction of tissue wounds. This study aims to demonstrate how to choose the correct size of rectangular expander in relation to wound size and the maximum advancement technique for wound coverage in order to achieve a successful outcome. The present study included patients who were operated on between January 2013 and January 2017. The expander height chosen was more than half the length of the wound and the expander width was chosen to be as wide as possible, based on the width of the wound. The expander was placed in a site adjacent to the wound. Maximum advancement method was used to achieve coverage of the wound. A total of 19 patients were included in the study, mean age 17.5 (range: 11-25) years. Indication included burn scar (n=14) and congenital nevus (n=5). The tissue expander was inserted into the scalp in 17 patients and supraclavicular area in two patients. A successful wound repair was achieved with the planned flaps in all patients. In expansion using rectangular expanders, the required expanded skin is gained through the height of the expanded tissue. Thus, expander size should be preoperatively planned to ensure the height of expanded tissue would be, at least, half of the wound length. Maximum benefit will be achieved from the expanded tissue through the correct placement of expanded tissue lateral flaps.

A new umbilicoplasty technique for the management of large umbilical hernia in children.

The ideal technique for reconstruction of proboscoid umbilical hernia in children is the subject of ongoing researches. The aim of this study is to describe our umbilicoplasty technique in the surgical repair of proboscoid umbilical hernia and report its results. The study included 21 children presented with a proboscoid umbilical hernia from 2014 to 2018. All patients had umbilicoplasty by the following technique: skin incisions were marked then a circular incision was made starting near the umbilical scar. We repaired the fascial defects then excised the lateral twin isosceles triangular flaps. A new umbilical depression was created by subcutaneous sutures fixing the center of the umbilical scar to the aponeurosis. We evaluated the results of surgery as excellent, fair or bad based on the criteria of the peripheral rim (raised, flattened or depressed); in addition to the central depression (deep, shallow or absent). The study included 12 boys (57%) and the age ranged from 19 to 67months. The mean duration of the procedure was 45min and the mean hospital stay was 1day. All patients had excellent early results and after 12months follow-up, the umbilicus was naturally looking and had an excellent peripheral rim and a central depression. The described umbilicoplasty technique in the surgical repair of proboscoid umbilical hernia in children is simple and easy with excellent aesthetic results.

Effect of skin soft tissue expansion on repair of large area of scars on extremities

Objective: To investigate the effect of skin soft tissue expansion on repair of large area of scars on extremities. Methods: Twenty-five patients with large area of scars on extremities were admitted to our department from June 2007 to October 2014. There were 14 males and 11 females, aged 4 to 36 years. Operations were performed under local infiltration anesthesia or general anesthesia. In the first stage, 1 to 5 cylindrical expanders with capacities of 250 to 600 mL were placed at left or right sides or at upper or lower parts of the scars. In the second stage, scars of 21 patients were repaired with expanded transverse propulsive and lateral flaps, and scars of 4 patients were repaired with expanded perforator flaps whose pedicles were perforators of brachial artery, superior ulnar collateral artery, or posterior interosseous artery according to areas and shapes of the scars. The secondary wound areas ranged from 13 cm×7 cm to 34 cm×18 cm after dissolution or excision of scars. The areas of flaps ranged from 13 cm×7 cm to 20 cm×12 cm. The donor sites were sutured directly. The flaps after operation and follow-up of patients were observed and recorded. Results: All expanded flaps survived after operation. And the superficial distal part of flap whose pedicle was perforator of posterior interosseous artery in one patient was with necrosis, and other flaps survived well. During follow-up of 3 to 15 months after operation of the second stage, color and texture of flaps were similar to surrounding skin, while extremities of donor sites were thinner and auxiliary incisional scars formed after expansion. Conclusions: Expanded flap is a good way to repair large area of scar on extremities. Bilateral skin of scar is the first choice of donor site of expanded flap. If there isn't enough skin for expanding on bilateral sides, expanded perforator flap designed at upper or lower part of the scar is another choice to repair the scar.

Clinical effects of heel lateral flap in repair of skin and soft tissue defects at posterior heel region

Objective: To explore the clinical effects of heel lateral flap in repair of skin and soft tissue defects at posterior heel region. Methods: From September 2007 to April 2016, 24 patients (17 males and 7 females, aged 16-70 years) with skin and soft tissue defects at posterior heel region were admitted to our department. The size of skin and soft tissue defects after debridement ranged from 3.0 cm×2.0 cm to 5.0 cm×4.0 cm. The defects were repaired with heel lateral flaps, with size ranging from 3.5 cm×2.5 cm to 6.0 cm×5.0 cm. The flaps were transferred to the donor sites through the loose subcutaneous tunnel. The donor site was repaired by full-thickness skin graft collected from inguinal region. The survival of flaps and the follow-up of patients were observed. Results: All flaps of 24 patients survived successfully. The recipient sites and donor sites were all healed. The patients all had follow-up of 6 to 24 months. At the last follow-up, the flaps were in good shape, with nearly normal color and soft texture. There were 6 cases of grade S3 sensation and 16 cases of grade S3(+) sensation. The distance of two-point discrimination of flaps ranged from 6 to 11 mm. The lateral foot skin grafts healed well, and the skin of the lateral foot was numb in the range of 4.0 cm×2.0 cm to 9.0 cm×3.0 cm. Conclusions: Heel lateral flap can not only repair the skin and soft tissue defects in the posterior region, but also reconstruct the sensory function of the posterior region. It is an ideal method to repair the skin and soft tissue defects in the posterior region.

The Paisley Pattern Breast Reduction.

Skin resection patterns inform the shape and scars after breast reduction. The 2 most commonly performed skin resection patterns, the Wise pattern and vertical pattern, each have limitations. The most common challenge is addressing excess lateral skin while avoiding medial scars. The Paisley Pattern breast reduction addresses this by incorporating lateral dogear excision in the skin resection design. Thirty consecutive patients received a Paisley Pattern breast reduction. After institutional review board approval, a chart review was performed to evaluate resection weight, operative time, American Society of Anesthesiologists class, flap necrosis, and seroma. Operative times were comparable to published times for the Wise and vertical pattern techniques. No patients had lateral flap necrosis, and no patients required a return to the operating room during the follow-up period. One patient developed a unilateral seroma that was drained by interventional radiology. This report of a novel skin resection design demonstrates a proof of concept that the skin resection pattern can be performed safely in a wide variety of patients. Although there is a learning curve to the technique to prevent over-resection laterally, it provides efficient and aesthetically acceptable alternative to the Wise and vertical skin resection patterns for both large and small reductions.

Clinical application of lateral supramalleolar perforator flap with the rotation point down on the repair of forefoot soft tissue defect

Objective To investigate the clinical effect of lateral supramalleolar perforator flap with the rotation point down on the repair of forefoot soft tissue defect. Methods From January, 2016 to June, 2017, 23 cases(15 males and 8 females) of forefoot soft tissue defect were repaired by lateral supramalleolar perforator flap with the rotation point down. The age ranged from 8 to 67 (mean, 42.9) years. The soft tissue defects were located far from the tarsometatarsal joint of the foot and the areas were 4.0 cm×4.0 cm-8.0 cm×12.0 cm. The areas of flap stitched directly or take blade thick skin repair on the thigh. All cases were followed-up by telephone or Internet, outpatient visit and home visit. Results Twenty-one cases survived successfully. Small area necrosis occurred at the distal end of the flap in 1 case, and healed after changing treatment. In the other cases, tension blister appeared at the distal end of the flap. After cut off some surgical stitches, the flap survived. All cases were followed-up from 6 to 12 months. The shape of flaps were not bloated and had good textures. The walking of affected limbs had no significant effect, and the functional recovery was satisfactory. Conclusion The lateral supramalleolar perforator flap is easy to cut and the perforator of flap is constant, which is a appropriate flap to repair the soft tissue defect of the forefoot. Key words: Lateral supramalleolar perforator flap; Rotation point; Forefoot; Soft tissue defect; Repair

Morphology and molecular analysis of Paratylenchus chongqingensis n. sp. (Nematoda: Paratylenchinae) from soil associated with Ophiopogon japonicus in China

Paratylenchus chongqingensis n. sp. extracted from the soil associated with Ophiopogon japonicus in China is described and illustrated. The new species is characterized by having the female with a body length of 243–274.5 μm, stylet 21–24.5 μm long, lip region distinctly set off forming a flattened labial disc, lateral field with three lines, lateral vulval flaps distinct, tail with a beak-like and subacute terminus; male with a 224.5–246.5 μm long body, spicules 13–14.5 μm long, stylet lacking and pharynx degenerate, tail tapering gradually, and then becoming narrow abruptly near the terminus, forming a short pointed filiform tail tip. The internal transcribed spacer sequences of the ribosomal RNA (ITS rRNA) gene of the new species were amplified and sequenced. The phylogenetic relationships of this new species with other Paratylenchus spp. using the ITS rRNA gene is given in this study.

Application of reconstruction of submammary fold with lateral thoracic wall adipofascial flap after nipple-areola complex sparing mastectomy in elderly breast cancer

Objective To evaluate the value of reconstruction of submammary fold with lateral thoracic wall adipofascial flap after nipple-areola complex sparing mastectomy(NSM) in elderly patients with breast cancer. Methods To retrospective analysis 20 cases of elderly patients with breast cancer were admitted from March 2016 to June 2018 in Beijing Tongren Hospital, Capital Medical University using reconstruction of submammary fold with lateral thoracic wall adipofascial flap after NSM(study group). Twenty-two elderly patients with breast cancer who had breast-conserving and sentinel lymph node biopsy were selected as control group. The operation time, drainage tube retention time, postoperative hospitalization time, postoperative complications, breast contour satisfaction were statistically analyzed. The measurements were expressed as mean±standard deviation (Mean±SD), and t-test was used for inter-group comparison, and Chi-square test was used for inter-group comparison of counting data. Results All cases were followed up for 3-27 months without local recurrence and distant metastasis. The difference in operative time between the study group and control group was statistically significant [(2.085±0.163 1) h vs (1.918±0.159 3) h, P=0.002]. There was no significant difference between the study group and control group in drainage tube removal time(5.25±0.910) d vs (5.27±0.767) d, hospitalization days(6.25±0.910) d vs (6.27±0.767) d, breast contour satisfaction rate (90.0% vs 81.8%) (P>0.05). Postoperative necrosis and liquefaction of adipofascial flaps occurred in 1 case in the study group and delayed healing occurred. Conclusion For some early-stage elderly breast cancer, reconstruction of submammary fold with lateral thoracic wall adipofascial flap after NSM, at the same time of radical surgery, can ensure the basic breast shape, avoid the chest wall deformity caused by traditional radical mastectomy, and improve the appearance and quality of life after mastectomy. Key words: Aged; Breast neoplasms; Lateral thoracic wall adipofascial flap; Reconstruction of submammary fold

The comparison of Crystallized phenol with Lateral Flap method in treatment of sinus pilonidalis

The comparison of Crystallized phenol with Lateral Flap method in treatment of sinus pilonidalis

Application of muscular flap and induced membrane technique in the emergency treatment for limb salvage for Gustilo type III B and III C open fracture of lower leg

Objective To investigate the clinical effectivity of the muscular flap transposition and induced membrane technique in the emergency treatment for the limb salvage of Gustilo type III B/C open fracture of lower leg. Methods From July, 2015 to December, 2017, 10 cases of Gustilo type III B/C fracture of lower leg with bone defects were performed limb salvage surgery. Induced membrane technique was used to fill the bone defects in the emergency room. The gastrocnemius and/or soleus muscular flaps were transposed to cover the bone cement or exposed bone simultaneously in emergence treatment. After the wound healed completely, traditional bone grafting was used to repair the bone defects. There were 4 cases of Gustilo type III B and 6 cases of Gustilo type III C. The average length of bone defect was (5.25±1.70) cm ranging from 3.0 cm to 11.0 cm. The gastrocnemius medial head flaps were performed in 5 cases, the combined application with the gastrocnemius medial head flaps and the medial hemimuscular flaps of soleus were performed in 2 cases, and medial hemimuscular flaps of soleus were transposed in 3 cases. Results The wounds in 6 cases were healed at one stage, but 2 cases healed by dressing because the exudate after skin grafting. In 1 case, the cross-leg flap was used to cover the exposed bone cement due to the necrosis of soleus flap. The other 1 was performed the transposition of the lateral gastrocnemius flaps because the exposure of bone cement after the necrosis of the upper and lateral muscles in lower leg. In the second-stage, the bone defects were reconstructed by traditional bone grafting. The average healed time of bone was 7.2 months ranging from 5 months to 9 months. At the last followed-up time, all patients recovered their function of weight-bearing. The Paley's score of the adjacent joints: excellent in 8 cases and good in 2 cases. Conclusion The combination with induced membrane technique and local muscular flap transposition in emergency surgery is an effective method to limb salvage for the Gustilo type III B/C open fracture of lower leg. Key words: Gustilo type III, Gustilo type; Open fracture of lower leg; Induced membrane technique; Muscular flap; Emergency treatment

Lamellar rotation surgery: a new procedure for repairing upper eyelid defects

BackgroundTo report “Lamellar Rotation Surgery”,a new technique for repairing large and moderate full-thickness upper eyelid defects.MethodsA two-stage technique is described in which a vertical incision is made in the tarsus of the lower eyelid with elevation of the lateral posterior lamella while sparing the lower eyelid orbicularis and skin to be rotated superiorly to form the reconstructed posterior lamella of the upper eyelid. Additionally, a lateral periosteal flap is used to reconstruct the lateral canthal tendon, and a McGregor procedure is used to reconstruct the anterior lamella of the upper eyelid. The flap is divided during a second-stage surgery at 3 months. Three cases are described to showcase this technique.ResultsGood functional and aesthetic results were achieved for the eyelids.ConclusionsThis new procedure may help to address the challenge of repairing full-thickness defects of the upper eyelid.Trial registrationRegistration number: ChiCTR1800018990, 20 Oct 2018, retrospectively registered.

Effect of lateral malleolus perforator flap for the repair of soft tissue defect of foot and ankle

Objective To study the effect of lateral supramalleolar perforator flap for skin and soft tissue defect of lateral malleolus. Methods From January 2012 to December 2015, 36 patients with soft tissue burn of ankle in the Traditional Chinese Medicine Hospital of Cixi were selected as study objects.The average wound area was 4~10cm.The average flap size was 5~13cm.There were 17 cases received skin flap of behind perforator of the lateral malleolus.There were 19 cases received skin flap of front perforator of the lateral malleolus.The effect of repair was observed. Results All flaps survived in 36 cases after operation.There were 7 cases of 2.6cm of blood stasis, and necrosis occurred in 2 cases which healed after dressing change.Transplantation of skin flap and the original skin had good adhesion, skin color and texture was similar to the surrounding skin during the follow-up period of 6 to 12 months.The survival time and walk time of the repair of anterior perforator flap were (2.20±0.70)weeks, (4.70±1.10)weeks, respectively, which were longer than those of the lateral retromalleolar perforator flap[(2.10±0.80)weeks, (4.20±1.10)weeks], but the differences were not statistically significant (all P>0.05). The American orthopaedic foot and ankle society(AOFAS) score of the anterior perforator flap was significantly lower than that of the lateral retromalleolar perforator flap, the difference was statistically significant[(77.47±3.41)points vs.(80.12±4.12)points, t=2.110, P<0.05]. Conclusion Lateral supramalleolar perforator flap has significant effect for skin and soft tissue defect of lateral malleolus.The operation is simple, the success rate is high, it is worth to be popularized in clinical. Key words: Ankle injuries; Soft tissue injuries; Surgical flaps; Reconstructive surgical procedures

The Lateral Thigh Perforator Propeller Flap

The Lateral Thigh Perforator Propeller Flap

A redescription of Liangwangshania biloba Chen, 2005, from the Chengjiang biota (Cambrian, China), with a discussion of possible sexual dimorphism in fuxianhuiid arthropods

Material attributed to Liangwangshania biloba, a fuxianhuiid arthropod from the lower Cambrian (Series 2, Stage 3) of southwest China, is redescribed, with many specimens illustrated for the first time. Newly recognized features include, potential optical neuropils, a stout posterolateral carapace spine, serrated tergal pleurae, two rows of mediolateral carinae, an abdomen composed of seven segments, the last possessing a tripartite lateral flap, and a triangular telson. The presence of tergal carinae, a prothorax composed of six segments, and a trunk composed of 43 segments tipped with a flap-like terminal segment, increase similarities with the previously described Shankouia zhenghei, thus prompting a reevaluation of the potential synonymy of these taxa. These previously recognized species also show considerable overlap in body size, and the ratios of selected body features, such as the carapace. This, combined with their co-occurrence over a temporally and geographically limited range, further support their synonymy. L. biloba is considered the senior synonym in accordance with ICZN rulings, with morphological differences, specifically the presence of posterolateral spines on the carapace, serrated tergopleurae, and spines on the terminal abdominal segment, attributed to sexual variation. An evaluation of potential sexual dimorphism in other fuxianhuiids, and a reassessment of terminology applied to this group is also provided.

Pedicled, innervated vastus lateralis (PIVL) flap for abdominal wall incisional hernia following kidney transplant and its proposed use in large lateralised incisional hernia - A new application for an established technique

Pedicled, innervated vastus lateralis (PIVL) flap for abdominal wall incisional hernia following kidney transplant and its proposed use in large lateralised incisional hernia - A new application for an established technique

Different reverse points of forward lateral malleolus perforator flap in the repair of skin and soft tissue defect of ankle or dorsal foot

Objective To discuss the clinical effects of forward lateral malleolus perforator flap in the repair of skin and soft tissue defect of ankle or dorsal foot. Methods From November, 2014 to June, 2017, 16 cases of skin and soft tissue defect in ankle or dorsal foot had been repaired, which were 11 males and 5 females, aged from 25 to 58 years old(average, 32.5 years). The rotation points were on proximal 5 cm of the lateral malleolus in 11 cases and on the level of tarsal sinus in 5 cases. The largest flap was 10.0 cm×18.0 cm and the smallest flap was 6.0 cm×4.0 cm. The color, thickness, texture, sensation, appearance, donor site shape and functional were followed-up after operation. Results All the 16 patients were followed-up from 1 to 24 months. The distal flap appeared dark in 1 case 2 days after operation, and blood supply was improved after stitches; One case was superficial necrosis and healed after dressing. All the flaps had good appearance and texture, no pigmentation, scar contracture, and so on. Conclusion The forward lateral malleolus perforator flaps have perforator constantly and the color, thickness are similar with the receiving areas, the rotation point could on proximal 5 cm of the lateral malleolus and on the level of tarsal sinus, which is a good method to repair skin and soft tissue defect of ankle or dorsal foot. Key words: Forward lateral malleolus perforator flap; Dorsal foot; Ankle; Skin and soft tissue defect; Repair

Distally Based Lateral Hemi-soleus Muscle Flap for Osseous and Soft Tissue Defects as a Complication of Total Ankle Replacement: A Case Report

As the number of total ankle replacement implantations performed in the United States continues to increase so does the development of associated complications to ensue. One of the major complications often encountered is that of periprosthetic infections, which tend to result in significant soft tissue defects relative to the distal one-third of the lower leg. In such cases, the soft tissue defects that arise create an extremely problematic situation for both patients and physicians combined, especially given the limited treatment options available to date. With that said, local tissue reconstruction with transpositional and reverse muscle flaps should always be considered regarding options for treatment. Here, we present the case of a 64-year- old woman with a past medical history of a prior bi-malleolar ankle fracture ORIF with subsequent post-traumatic ankle arthritis. Due to the patient’s post-traumatic symptoms, a total ankle replacement was performed. This case outlines how a reverse transpositional lateral hemi-soleus muscle flap was successfully implemented for the management and treatment of a distal anterior soft tissue ankle defect with exposed tendon status-post total ankle arthroplasty.