Random Flaps Research Articles

Concurrent Staged Cheek Random Pedicle Flap and Island Pedicle Advancement Flap for Reconstruction of Full Nasal Alar–Free Margin and Upper Cutaneous Lip Mohs Defect

Concurrent Staged Cheek Random Pedicle Flap and Island Pedicle Advancement Flap for Reconstruction of Full Nasal Alar–Free Margin and Upper Cutaneous Lip Mohs Defect

Transplantation of Adipose-Derived Stem Cells Before Flap Expansion and After Expanded Flap Elevation Result in Different Effects.

Studies of using mesenchymal stem cells to assist skin and soft tissue expansion have shown that stem cells can improve expansion efficiency through promoting tissue regeneration. However, the issue that whether the flap viability is also improved is unknown. Sixteen pigs were equally divided into 2 groups. A pair of 150 mL expanders was symmetrically inserted into each pig's dorsum. Group 1 received adipose-derived stem cells (ADSCs) injection before expansion, and group 2 received ADSCs grafting after flap elevation. After 4 weeks' expansion, a random flap measuring 2 cm × 16 cm was elevated along the long axis of each expanded flap on the pigs' back. Flap viability was measured at postoperative day 7. Histological analysis and cell tracking were performed. The expression of vascular endothelial growth factor was determined. The flap viability of the ADSCs-grafted expanded flap (75.5 ± 6.6%) was similar to the control (69.4 ± 8.4%) in group 1 (transplantation before expansion). However, in group 2 (transplantation after flap elevation), the ADSCs-grafted expanded flap had a higher flap viability (92.6 ± 5.7%) compared with control (66.2 ± 7.4%). Moreover, the ADSCs-grafted expanded flap in group 1 showed increased skin thickness, collagen content, cells proliferation, vascularization, and vascular endothelial growth factor expression. Cell tracking showed that the positively stained cell differentiating into an endotheliocyte could be seen in group 2. Transplantation of ADSCs before tissue expansion does not improve flap viability but can promote tissue regeneration. Injection of ADSCs after flap elevation can increase the surviving rate of the expanded flap.

Effects of platelet-rich plasma on the survival of ultra-long dorsal random flaps in rats

Objective: To observe the effects of platelet-rich plasma (PRP) on the survival of ultra-long dorsal random flaps in rats. Methods: Sixteen male Sprague Dawley rats aged 6 to 8 weeks (the same below) were sacrificed to collect whole blood of 9 to 10 mL from each rat, and PRP was prepared by modified APPLE method. The platelet count of retained whole blood and PRP detected by automated blood cell analyzer showed that PRP was made successfully. The other thirty-two rats were collected and divided into PRP group and control group according to the random number table, with 16 rats in each group. One rectangular ultra-long random flap with area of 8 cm×2 cm was made on the back of each rat and replanted in situ. The equidistant 3 points were designed on both sides of the flap of each rat. Rats in PRP group were injected with 0.1 mL PRP from dermis and subcutaneous tissue of each injection point, while rats in control group were injected with the same volume of normal saline. Eight rats in each group were sacrificed at post operation hour (POH) 24 and on post operation day (POD) 7. On POD 7, survival of flaps of rats in 2 groups was observed, and the survival rates of flaps were calculated. On POD 7, the proximal, middle, and distal flaps of rats in 2 groups were collected, and histological changes of the flaps of rats in 2 groups were observed with hematoxylin-eosin staining. At POH 24 and on POD 7, flaps in 3 to 4 cm to pedicles were taken to detect mRNA expressions of vascular endothelial growth factor (VEGF), platelet-derived growth factor AA (PDGF-AA) and PDGF-BB by real-time fluorescent quantitative reverse transcription polymerase chain reaction, and to determine content of nitric oxide by nitrate reductase method. Data were processed with t test. Results: (1) On POD 7, flaps of rats in PRP group were dry without purulent exudate, and covered with scab, and the pink new skin emerged after scab fell off. On POD 7, flaps of rats in control group were with a large amount of inflammatory exudates, 1/2 to 2/3 of flaps at the distal were with necrosis and covered by scab which was not easy to be stripped. The survival rate of flap of rats in PRP group was (67±6)%, significantly higher than (52±10)% of rats in control group (t=1.94, P<0.05). (2) There were no obvious inflammatory cell infiltration and a number of microvessels, and fibrous tissue arranged neatly in the proximal flaps of rats in PRP group. There were a few of inflammatory cell infiltration and a number of microvessels, and fibrous tissue arranged slightly disorderly in the middle flaps of rats in PRP group. There were many more inflammatory cell infiltration and microvessels, a small amount of vascular embolism, and fibrous tissue arranged disorderly in the distal flaps of rats in PRP group. There were a large number of inflammatory cells infiltration and a few of microvessels, and fibrous tissue arranged disorderly in the proximal, middle, and distal flaps of rats in control group. (3) At POH 24 and on POD 7, mRNA expressions of VEGF, PDGF-AA, and PDGF-BB of rats in PRP group were significantly higher than those of rats in control group (t=6.46, 5.61, 2.88, 10.18, 6.10, 7.67, P<0.001). (4) At POH 24, content of nitric oxide in flap of rats in PRP group was (5.0±0.9) μmol/g, significantly higher than (3.4±0.9) μmol/g of rats in control group (t=19.14, P<0.001). On POD 7, content of nitric oxide in flap of rats in PRP group was (3.3±0.8) μmol/g, which was close to (3.0±0.6) μmol/g of rats in control group (t=2.93, P>0.05). Conclusions: PRP can improve the survival rate of ultra-long dorsal random flap in rats, which may be related to regulation of angiogenesis related factors, increase of nitric oxide content, and inhibition of excessive apoptosis of cells of PRP, so as to alleviate ischemical reperfusion injury and improve microcirculatory disturbance.

Experimental study on the effect of desferrioxamine on targeted homing and angiogenesis of bone marrow mesenchymal stem cells

To investigate whether desferrioxamine (DFO) can enhance the homing of bone marrow mesenchymal stem cells (BMSCs) and improve neovascularization in random flaps of rats. BMSCs and fibroblasts (FB) of luciferase transgenic Lewis rats were isolated and cultured. Forty 4-week-old Lewis male rats were used to form a 10 cm×3 cm rectangular flap on their back. The experimental animals were randomly divided into 4 groups with 10 rats in each group: in group A, 200 μL PBS were injected through retrobulbar venous plexus; in group B, 200 μL FB with a concentration of 1×10 6 cells/mL were injected; in group C, 200 μL BMSCs with a concentration of 1×10 6 cells/mL were injected; in group D, cells transplantation was the same as that in group C, after cells transplantation, DFO [100 mg/(kg·d)] were injected intraperitoneally for 7 days. On the 7th day after operation, the survival rate of flaps in each group was observed and calculated; the blood perfusion was observed by laser speckle imaging. Bioluminescence imaging was used to detect the distribution of transplanted cells in rats at 30 minutes and 1, 4, 7, and 14 days after operation. Immunofluorescence staining was performed at 7 days after operation to observe CD31 staining and count capillary density under 200-fold visual field and to detect the expressions of stromal cell derived factor 1 (SDF-1), epidermal growth factor (EGF), fibroblast growth factor (FGF), and Ki67. Transplanted BMSCs were labeled with luciferase antibody and observed by immunofluorescence staining whether they participated in the repair of injured tissues. The necrosis boundary of ischemic flaps in each group was clear at 7 days after operation. The survival rate of flaps in groups C and D was significantly higher than that in groups A and B, and in group D than in group C ( P<0.05). Laser speckle imaging showed that the blood perfusion units of flaps in groups C and D was significantly higher than that in groups A and B, and in group D than in group C ( P<0.05). Bioluminescence imaging showed that BMSCs gradually migrated to the ischemia and hypoxia area and eventually distributed to the ischemic tissues. The photon signal of group D was significantly stronger than that of other groups at 14 days after operation ( P<0.05). CD31 immunofluorescence staining showed that capillary density in groups C and D was significantly higher than that in groups A and B, and in group D than in group C ( P<0.05). The expressions of SDF-1, EGF, FGF, and Ki67 in groups C and D were significantly stronger than those in groups A and B, and in group D than in group C. Luciferase-labeled BMSCs were expressed in the elastic layer of arteries, capillaries, and hair follicles at 7 days after transplantation. DFO can enhance the migration and homing of BMSCs to the hypoxic area of random flap, accelerate the differentiation of BMSCs in ischemic tissue, and improve the neovascularization of ischemic tissue.

The versatile use of fasciocutaneous flaps in coverage of extensive soft tissue defects

<br><b>Background:</b> Coverage of large soft tissue defects has always been difficult. Despite an increase in free flap options and many of combinations, it is still a big problem to repair large defects in some patients. In this study, repair of large defects with random fasciocutaneous flaps prepared from adjacent regions to the defect has been evaluated in functional and esthetic terms, especially in cases where microsurgery methods cannot be implemented or do not suffice. <b>Patients and Methods:</b> Ten patients' large soft tissue defects in different regions were repaired with random fasciocutaneous flaps. Average defect size was 15.2 cm × 18.3 cm, and defects were covered with random flaps with an average size of 14.8 cm × 28.1 cm. Average operation duration and average hospital stay were measured at 2.7 h and 2.2 days, respectively. <b>Results:</b> Patients were followed for 6 months on average. Complications such as flap loss, bleeding, or infection were not encountered in any patient at an early or late stages. Recovery of donor sites was evaluated unproblematic, and esthetic appearance was regarded acceptable. <b>Conclusion:</b> Fasciocutaneous flaps neighboring the defect can be prepared in larger dimensions compared to their alternatives, and they can cover the defect with less problems. Producing quite successful results is highly possible, especially in cases where the use of free and axial flaps is inappropriate. With the rapid development in microsurgery, many flap alternatives have emerged for the coverage of basic or complicated defects. However, random fasciocutaneous flaps have to be kept in mind as they are more basic and often have the potential to produce better and more effective results than these methods.<br>

Association of Electronic Cigarette Vaping and Cigarette Smoking With Decreased Random Flap Viability in Rats.

Smoking is a known risk to wound healing, but whether electronic cigarettes present the same risk remains unknown. To evaluate the rate of flap necrosis in the e-cigarette vapor-exposed group and the unexposed control and to detect a difference in the rate of flap necrosis between the traditional cigarette smoke-exposed group and the unexposed control. From March 10, 2018, to May 4, 2018, a cohort study was conducted on 45 male Sprague-Dawley rats at Boston University School of Medicine. Each rat weighed approximately 100 g at the beginning of the study and was randomized to 1 of 3 groups: negative control (n = 15), experimental (exposed to e-cigarette vapor; n = 15), and positive control (exposed to traditional cigarette smoke; n = 15). Rats in the experimental and positive control groups were exposed to electronic cigarette vapor and traditional cigarette smoke in a smoking chamber for 30 minutes twice a day for 30 consecutive days. Levels of serum cotinine were monitored and maintained between 150 ng/mL and 200 ng/mL. After 30 days, random pattern dorsal skin flaps were raised. Percentage of flap necrosis for each group. All 45 rats survived the surgical procedure and postoperative recovery, and all rats thrived and gained weight over the course of the study. The highest rate of flap necrosis was found in the positive control cohort, with a mean (SD) of 68.7% (8.6%), followed by the experimental cohort, with a mean (SD) of 65.9% (11.8%); the negative control cohort had the least amount of flap necrosis, with a mean (SD) of 50.8% (9.4%). The percentage of flap necrosis in the negative control rats (95% CI, 46.0-55.6; P < .001) was substantially lower than that for both the positive control rats (95% CI, 64.3-73.0; P < .001) and the experimental rats (95% CI, 59.9-71.8; P < .001). No statistically significant difference in flap necrosis was noted between the rats in the experimental cohort and the rats in the positive control cohort (95% CI, 59.9-71.8 vs 95% CI, 64.3-73.0; P = .46). Smoking and vaping appear to be equally detrimental to wound healing and to be associated with a statistically significant increase in flap necrosis compared with the unexposed group. The results suggest that vaping should not be seen as a better alternative to cigarette smoking in the context of wound healing. NA.

The suprapubic deepithelialized inferiorly based random flap designed to fill the tissue deficiency at supraumbilical area to prevent the concave deformity in abdominoplasty

<br><b>Introduction:</b> The most critical tissue in abdominoplasty is the midsagittal part of the supraumbilical region with the highest risk of hemodynamic disturbance. Here, the skin is also thinner compared to the neighboring lateral tissues. This may result in postoperative suprapubic depression. <b>Methods:</b> An easy technique is designed to prevent this suprapubic depression. While making the transverse incision, deepithelialized suprapubic flap is kept in place attached to the suprapubic region. The medial supraumbilical deficient tissue is brought down with the abdominoplasty flap and lowered over the deepithelialized suprapubic flap. <b>Results:</b> Follow-up with the patients is between 1 month and 2 years. We have no longer observed any concave deformity. <b>Discussion:</b> Another technique described in the literature designed to prevent the concave deformity is deepithelization of the tongue of tissue projecting from the lower end of the abdominal flap and folding this back to double up the thickness of fat in this area. Nevertheless, the median distal end of the abdominal flap is hemodynamically the poorest part of the flap. Preparing deepithelialized tongue and folding it back raises the vascular insufficiency risk. Suturing the upper edge and the sides of the supraumbilical flap to deep tissues of the abdominal flap distribute the tissue tension to deeper parts, thus reduce the incision tension with reduced scar tension at the midline. <b>Conclusion:</b> The suprapubic random flap is an assurance for prevention of concave deformity and helps to reduce the tension of transverse incision at the midline, thus may reduce the risk of scar formation.<br>

Safe and easy way to reconstruct pressure ulcers: Gluteal artery perforator flaps

Introduction: Pressure ulcers continue to be a reconstructive challenge due to the growing number of patients under risk. Frail nature of the affected patient makes this problem even more complicated. Commonly pressure ulcers are reconstructed with random pattern flaps or musculocutaneous flaps. With the emergence of the perforator concept and expanding knowledge in the vascularity of the gluteal integument, gluteal artery perforator flaps became popular in reconstructing pressure ulcers. In this study, we aimed to review the technical tips to improve clinical outcomes of superior gluteal artery perforator and inferior gluteal artery perforator flaps in the light of our clinical experience. Materials and Methods: Between 2015 and 2018, nine patients with pressure ulcers in the sacral and ischial regions were reconstructed with gluteal artery perforator flaps. Anatomical landmarks were marked, and Doppler ultrasound was also used to identify individual perforators. The subfascial dissection was opted, and skin island was inseted resembling an advancement pattern to prevent peforator kinking and to include maximum number of perforators. Results: All flaps survived, seroma was seen in two patients, and two of the patients had wound dehiscence at donor site. Conclusions: In the era of perforator flaps, with their safe anatomical basis, less morbidity and versatility in design we offer gluteal artery perforator flaps as a reliable alternative in reconstructing pressure ulcers.

Random pattern rotation flaps in the treatment of advanced sacrococcygeal pilonidal disease with damaged skin structure

Random pattern rotation flaps in the treatment of advanced sacrococcygeal pilonidal disease with damaged skin structure

Subdermal nitrous oxide delivery increases skin microcirculation and random flap survival in rats

Random skin flaps are essential tools in reconstructive surgery. In this study, we investigated the effect of subdermal nitrous oxide (N2O) application on random flap survival. In this experimental study, we used 21 female rats in three groups. In the N2O and air groups, gases were administrated under the proposed dorsal flap areas daily for seven days. Following the treatment period, flaps were raised and inserted back into their place from the dorsal skin. In the control group, the flaps were elevated and inserted back to their place without any pretreatment. Calculation of necrotic flap areas, histological examination and microangiography was performed to evaluate the results 7 days after the flap surgery. The average of necrotic flap area in the N2O, air and control group was 13.45%, 37.67% and 46.43%, respectively. (N2O vs air p = .044; N2O vs control p = .003). The average number of capillary formations identified in the histological analysis was 7.0 ± 1.58, 3.75 ± 2.36 and 4.4 ± 0.54 in the N2O, air and control group, respectively. (N2O vs air p = .017; N2O vs control p = .037). The average number of capillary structures identified in the angiography images were 6.3 ± 1.52, 1.6 ± 1.15 and 1.3 ± 0.57 in the N2O, air and control group, respectively. (N2O vs air p = .04; N2O vs control p = .02). We conclude that subdermal N2O application increases random flap survival through an increase in the skin microcirculation and could be promising for future clinical applications.

Random nasoseptal flap for revision skull base reconstruction

The nasoseptal flap (NSF) has become the workhorse of endoscopic skull base reconstruction (ESBR). With the increase in endoscopic skull base procedures, there has also been the need for staged and revision procedures where the use of the NSF is no longer an option. These cases have posed new and interesting challenges to skull base surgeons especially with regards to reconstructive options. While free mucosal or turbinate grafts may be too small for certain defects, others such as the pericranial flap require an open procedure with added morbidity. We describe the use of a random nasoseptal flap for the reconstruction of a skull base defect.

Use of Local Flaps for Soft-Tissue Closure in Diabetic Foot Wounds: A Systematic Review.

"A systematic review was undertaken to assess the outcomes of local random flaps in diabetic foot wound closure. The review was conducted using the following databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica dataBASE, Google Scholar, MEDLINE, Ovid, and PubMed. Search terms were local random flap, diabetes, foot, wound, ulceration, neuropathy, tissue transfer, V-Y, bilobed, monolobed, rotational, advancement, transpositional, rhomboid, and Limberg. English language studies, studies published from 1997 to 2017, patients with diabetes mellitus treated for foot wounds, use of local random flaps, follow-up period of 6 months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery were included. Isolated literature reviews and descriptions of only surgical technique and/or cadaveric studies were excluded. The initial search identified 53 eligible studies with 28 being excluded. The remaining 25 studies used for data extraction had a total of 512 patients in which 199 of these underwent 204 local random flap procedures. Average follow-up for the flaps was approximately >2 years, and successful wound closure at last follow-up was demonstrated in 75.5% of the studied population. Studies were found to be of generally low quality, with the majority composed of retrospective case series. Based on current available evidence found in this systematic review, local random flaps demonstrated a relatively high success rate when utilized for the definitive closure of diabetic foot wounds. However, because of a lack of high-quality evidence and substantial heterogeneity among the studies, the results should be interpreted with caution. Levels of Evidence: Level III: Systematic review.

Effect of botulinum toxin type A injection in the viability of dorsal flap in rats

Purpose: Botulinum toxin A (BoNTA) increased the viability of skin flap in healthy rats. Most of the studies injected this substance some days (7-15) before the flap surgery. This treatment is used only for elective surgery, there was no data about the efficacy of BontA when injected in the surgical period. This study aimed to analyze the effect of BontA on the viability of Random flap in a intra surgical injection. Methods: Twenty male Wistar rats (250–300 g) were randomly divided into four groups: saline injection 15 days prior the surgery (G1), BoNTA injection 15 days prior the surgery (G2), saline injection intraoperative period (G3), BoNTA injection intraoperative (G4). A dorsal cutaneous flap (3×10cm) was performed. Survival area and total area of the flaps were measured. Lumen diameter, external arterial diameter and lumen/wall thickness ratio were recorded. Results: Viable area increased in Bonta 15days group when compared to saline-15days (1080.7 ± 307.5 mm2 vs. 1594.5 ± 419.7mm2, p= 0.01) and in the Bonta –intraoperative injection when compared to saline intraoperative injection (1133.3 ± 462.0 mm2 vs. 1389.9 ± 320.4 mm2, p=0.014). The ratio viable area/total area showed similar results (G1 versus G2, 0.43 vs. 0.74; p&lt;0.001, respectively) and G3 versus G4 (0.44 vs. 0.61 p= 0,04). We did not find any difference in the microscopic analysis (lumen diameter, external arterial diameter and lumen/wall thickness ratio). Conclusion: BoNTA injected fifteen days before the surgery increased skin flap viability. However, BontA injected intraoperatory time did not increased the flap viability.

Effects of ultrathin abdomen flap on repairing deep electric burn wounds in finger of pediatric patients

Objective: To investigate the effects of ultrathin abdomen flap in repairing deep electric burn wounds in finger of pediatric patients. Methods: A total of 14 pediatric patients with simple electric burns in finger were admitted to our unit from March 2013 to October 2017. Six patients had electric burns in one finger, 5 patients had electric burns in two fingers, and 3 patients had electric burns in three fingers. The size of wounds in single finger ranged from 2.0 cm×1.0 cm to 3.5 cm×2.0 cm. After complete preoperative examination, wounds debridement and ultrathin abdomen flap repair operation were performed on 3 to 6 days post injury. Six pediatric patients were treated with abdominal random flap, 4 patients were treated with inferior epigastric artery paraumbilical perforator bilobed flap, and the other 4 patients were treated with superficial circumflex iliac artery bilobed flap. The size of flaps ranged from 4.0 cm×2.0 cm to 8.0 cm×4.0 cm. The donor sites were sutured directly. Results: The flaps of 14 pediatric patients survived well after operation, and no flap showed blood supplying disorder. During follow-up of 3 to 24 months, the appearance and function of fingers were good, and the donor sites recovered well, with no cicatrix contracture deformity. Conclusions: The ultrathin abdomen flap is one of the good choices for repairing deep electric burn wounds in finger of pediatric patients.

The Differential Use of Bilobed and Trilobed Transposition Flaps in Cutaneous Nasal Reconstructive Surgery.

Bilobed and trilobed transposition flaps are versatile random pattern transposition flaps that reliably restore nasal symmetry, topography, light reflex, and contour and are frequently used in cutaneous nasal reconstructive surgery. The authors wish to compare the characteristics of bilobed and trilobed flaps in cutaneous reconstructive surgery and to identify scenarios for their differential use. A retrospective chart review over 7 years of consecutive patients who underwent reconstruction with a bilobed or trilobed flap after Mohs micrographic surgery was performed. Statistical analysis of patient and surgery characteristics, anatomical distribution, postprocedural events, and need for revisions after both flap types was conducted. One hundred eleven patients with bilobed flaps and 74 patients with trilobed flaps were identified. Bilobed flaps are significantly more frequently used on the inferior nasal dorsum and on the sidewall, whereas trilobed flaps are significantly more frequently used on the nasal tip and infratip. No significant difference in postprocedural events (e.g., complications, erythema, trapdoor) was noted between the two flap types. Bilobed and trilobed transposition flaps are versatile means of repair for nasal reconstruction. Trilobed flaps may be used to repair defects in a more distal nasal location than bilobed flaps. Regardless of flap type, complications are rare. Therapeutic, III.

Varenicline increases random flap survival in rats submitted to nicotine

Smoking is a leading cause of flap failure. Varenicline-assisted smoking cessation has shown beneficial effects on vascular endothelial function. The aim of this study was to determine whether varenicline conveys beneficial effects for skin flap survival. Twenty-four rats were randomly divided into four groups of six. The rats in the control group received normal saline subcutaneous injections, and those in the nicotine group received subcutaneous nicotine injections. The rats in the varenicline group received varenicline intraperitoneally, and those in the nicotine-varenicline group received both nicotine and varenicline. At the end of week 3, the dorsal skin flaps were raised in all rats. On postoperative day 7, the flaps were evaluated by direct observation, microangiography, and light microscopy. The mean necrotic area of the flaps was significantly greater in the nicotine group than in the control group (49.2 ± 4.71 vs. 22.03 ± 0.93%, respectively, p < .01) and significantly higher in the nicotine-varenicline group than in the varenicline group (22.4 ± 1.23 vs. 9.2 ± 0.59%, respectively, p < .01). However, no significant difference was observed between the control and nicotine-varenicline groups (p = .934). Microangiographically, vascularity was lowest in the nicotine group and highest in the varenicline group. Histologically, larger areas of necrosis, more severe inflammation and less vessel formation were observed in the nicotine group. Healing, exhibited by a greater number of vessels, was evident in the varenicline-applied groups. Varenicline appears to increase the microcirculation of random flaps, as shown by decreased flap necrosis and increased vascularity.

Focus on anatomical aspects of soft tissue coverage options in elbow reconstruction: an updating review.

The elbow joint is particularly exposed to soft tissue injuries associated with fractures and dislocations. Different coverage options within the past decades for recovering loss of soft tissue defects around the elbow region have been proposed based on anatomical research. Our aim was to make an updated focus on the anatomical basis of different techniques of coverage of loss of tissues around the elbow. The main procedures of flaps were defined: local random, axial fasciocutaneous, local muscle pedicle, propeller and free microvascular flaps. A systematic literature review on anatomical basis on these different flaps options was conducted searching on PubMed databases and the selection process was undergone according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline. Inclusion criteria were: review and original articles, including anatomical basis of the procedures, in English and French languages. The final analysis included 37 relevant articles out of 1499 published references. 640 flaps were referenced, for covering 302 elbows. Local random flaps provide a good quality skin for small tissue defects in posterior elbow and periolecranon area, and depend on dermal and subdermal blood supply. Axial fasciocutaneous flaps have well-defined blood supplies and are designed as peninsular, island, or microvascular free flaps, as the radial forearm, lateral arm, ulnar artery, antecubital fasciocutaneous, and posterior interosseous flaps. Muscular flaps have advantages as strength, capacity to contrast local infection and to avoid empty spaces, and can be used as pedicle or as free transfers. Propeller flaps can be rotated up to 180° around an axis corresponding to the perforator vessel and do not require the sacrifice of a major artery or functional muscle. The concept of perforasome is evoked. Free microsurgical transfers can be proposed to cover any defect around the elbow. The anatomical basis of the flap's harvesting and the possibilities of elbow coverage are discussed through the selected articles. The different indications according to the areas of soft tissues defects are considered.

Clinical practice of repair of large tracheal defects with local tension free flaps

Objective: To investigate a simple and practical method for the repair of large tracheal defects. Methods: From April 2015 to October 2017, 10 patients with large tracheal wall defects after thyroid carcinoma underwent two phase repair with cervical tension free flap with modified design. In the longitudinal direction of the leakage, design two pieces of random flap outside the top angle of 45°, respectively, and the side turn double flip flap to repair the leak, outward and upward forming tension, avoid collapse after healing. Results: Large tracheal wall defects in 10 cases were successfully repaired, and normal respiration and language functions were recovered quickly.With following-up of 6-30 months(the medran was 12 months), the airway kept normal ventilation, no recurrence, and 1 patient with pulmonary metastasis had a stable condition. Conclusion: The modified tension free flap can be used for the repair of large defects of trachea with a good efficacy.

Postburn Neck Contracture: Principles of Reconstruction and a Treatment Algorithm.

Various techniques have been developed for postburn neck reconstruction, but a treatment algorithm is needed. We retrospectively reviewed all patients treated for postburn neck contracture at our institution between February 2008 and December 2015. Necks were divided into one anterior subunit and two lateral subunits marked by the sternocleidomastoid muscle. Deformities were categorized into three types according to their size and location. Type I deformities involve less than one subunit, type II deformities involve at least one subunit but less than two subunits, and type III deformities affect two or more subunits. Type II deformities were further divided into type IIa deformities, which mainly involve the anterior region, and type IIb deformities, which mainly involve the lateral region. Local random pattern flaps were constructed for type I deformities. Pedicled flaps from the anterior chest and supraclavicular areas were preferred for type IIa deformities, and pedicled flaps from the back were preferred for type IIb deformities. Pedicled flaps from other areas were the second choice for type II deformities, followed by free and prefabricated flaps. For type III deformities, bipedicled flaps were usually required. At a follow-up of at least 12 months, all patients showed near-normal neck function, and aesthetic features were significantly improved. The proposed classification and treatment algorithm for postburn neck reconstruction may help achieve satisfactory outcomes.

Clinical characteristics, classification and surgical treatment of periductal mastitis.

This study aimed to describe the clinical characteristics of periductal mastitis (PDM), propose the practical clinical classification system and evaluate the results of different surgical treatments in different type of PDM patients. A retrospective study was carried out at department of breast surgery, Peking Union Medical College Hospital, Beijing, China. A total of 152 patients with the diagnosis of PDM were reviewed from March 2012 to December 2016. All of the patients underwent surgery. Data were collected regarding clinical manifestation, treatment, and outcomes. The median age was 36 years. A subareolar breast mass was the most frequent symptom. The most common clinical manifestations were mass (98.0%), rubefaction (41.1%), nipple retraction (36.8%), abscess (36.8%), skin ulceration (25.7%), and mammary duct fistula (19.1%). Fourteen (9.2%) patients were recurrent PDM at first hospitalization. Eight (5.3%) patients had prolactinoma. Five (3.3%) patients were taking antipsychotic medications. Only four (2.6%) patients were smokers. Eight patients were highly suspected to be breast cancer before surgery. A four-type classification system was first proposed according to clinical manifestations. The different surgeries in each category were evaluated. After 3 years median follow-up, 11 (7.2%) patients got recurrence including two initial recurrent PDM. Periductal mastitis is a distinct benign breast condition of unknown etiology. Mass, abscess and fistula are most common manifestations of the disease. Wide surgical excision, fistulectomy and extended excision with transfer of a random breast dermo-glandular flap (BDGF) are effective surgical modalities for different type of PDM.