Superficial Inferior Research Articles

Novel Classification of the Branching Patterns of the Superficial Branch and the Deep Branch of the Superficial Circumflex Iliac Artery and the Superficial Inferior Epigastric Artery on Computed Tomographic Angiography.

Recent advances in the superficial circumflex iliac artery (SCIA) perforator flap transfer emphasized the necessity to comprehensively understand the lower abdominal vasculature. This study aimed to clarify the relationship among the superficial inferior epigastric artery (SIEA), the superficial branch (SCIAs), and the deep branch (SCIAd) of the SCIA. Computed tomographic angiography was retrospectively reviewed in 312 hemiabdomens in 161 female patients who underwent abdominal flap breast reconstruction. We assessed the presence, caliber, and branching patterns of the SCIA branches and the SIEA. The SIEA-SCIA common trunk was present in 40.1% of the hemiabdomen and was identified in either side of the abdomen in 63.6% of patients. At least one superficial vessel larger than 1.5 mm was found in 61.5% of hemiabdomens. Seven branching patterns of the SCIA-SIEA system were noted: (1) the SCIA and the SIEA originated together (17.0%); (2) the SIEA and the SCIAs shared an origin (22.8%), (3) the SCIA and the SIEA branched separately (17.0%), (4) each artery originated separately (8.0%); (5) the SCIAs and the SCIAd emerged together with the SIEA absent (17.3%); (6) the SCIAs and the SCIAd originated separately with the SIEA absent (13.1%); (7) the SIEA and SCIAd originated separately with the SCIAs absent (3.5%). SCIA-SIEA branching patterns were classified into seven distinctive patterns. This novel classification may help surgeons to choose the optimal pedicle when using the hemi-abdomen region as the donor site.

Superficial Inferior Epigastric Artery (SIEA) Flap is the Armamentarium for the Coverage of Large Complex Wounds on Dorsum of Hand in a Regional Medical College Hospital

As hand is a functional part of the body, dorsal surface of digits, hand and wrist is prone to injury causing complex wound. Thin, mobile and supple skin of the dorsal wrist and hand make significant for hand functions and aesthetic. Aims of the study were feasibility of the flap in terms of survivability of Superficial Inferior Epigastric artery (SIEA) flap, complications of flap and measurement of functional & aesthetic outcomes to achieve the reconstruction goal in hugely burden regional medical college hospital. 11 SIEA flaps were done in Rajshahi Medical College Hospital from August 2019 to July 2021 on both hands among both male and female patients. Only 2 (18.18%) flaps were lost partially. Almost all the wounds were covered successfully with good functional and aesthetic outcome. So, SIEA flap is the one of the best workhorses for extensive dorsal complex wound in overburdened regional medical hospital in Bangladesh.

Surgical Angiogenesis of Decellularized Nerve Allografts Improves Early Functional Recovery in a Rat Sciatic Nerve Defect Model.

Surgical angiogenesis applied to nerve grafts has been suggested to enhance nerve regeneration after nerve injury. The authors hypothesized that surgical angiogenesis to decellularized nerve allografts would improve functional recovery in a rat sciatic nerve defect model. Sixty Lewis rats were divided in three groups of 20 animals each. Unilateral sciatic nerve defects were repaired with (1) autografts, (2) decellularized allografts, and (3) decellularized allografts wrapped with a superficial inferior epigastric artery fascial flap to add surgical angiogenesis. Twelve and 16 weeks after surgery, nerve regeneration was assessed using functional, electrophysiologic, histologic, and immunofluorescence analyses. Ultrasonography was used during the survival period to noninvasively evaluate muscle atrophy and reinnervation by measuring cross-sectional muscle area. Surgical angiogenesis of allografts demonstrated significantly improved isometric tetanic force recovery at 12 weeks, compared to allograft alone, which normalized between groups at 16 weeks. Cross-sectional muscle areas showed no differences between groups. Electrophysiology showed superiority of autografts at both time points. No differences were found in histologic analysis, besides a significantly inferior N ratio in allografts at 12 weeks. Immunofluorescent expression of CD34, indicating vascularity, was significantly enhanced in the superficial inferior epigastric artery fascial group compared to allografts at 12 weeks, with highest expression at 16 weeks compared to all groups. Surgical angiogenesis with an adipofascial flap to the nerve allograft increases vascularity in the nerve graft, with subsequent improvement of early muscle force recovery, comparable to autografts.

Breast Reconstruction for Cancer Patients in COVID-19 Pandemic.

Breast reconstruction is considered an integral aspect of breast cancer treatment and has a well-known positive effect on quality of life. Surgical treatment of cancer has been delayed until evaluation of local circumstances of coronavirus disease of 2019 (COVID-19), adding to reasons why breast reconstruction procedures may have been delayed.1 In developing countries and middle-income economies, breast reconstruction has had a slow growth; even now, some countries do not cover breast reconstructive surgery, and we were just starting to see progress on the subject in recent years.2 We think breast reconstruction should not be abandoned as an important subject in benefits for cancer patients, even during this pandemic. At our institutions, we continue to offer breast reconstruction surgery, even during the COVID-19 pandemic (Fig. 1). To achieve this, we offer short-recovery surgical procedures to reduce patient exposure to coronavirus. We even try to favor a same-day surgery approach. This could mean direct-to-implant surgery when feasible or tissue expander placement when a second surgery would be required. We also look for options that reduce patient hospital stay, such as enhanced recovery after surgery protocols; combined anesthesia, with local blockades to reduce the effects of intravenous medications (e.g., nausea and vomiting) to favor shorter hospital stays; and oral intubation to contain aerosolization of virus for the protection of the surgical team.3 Immediate reconstruction will favor less exposure to coronavirus, avoiding at least one subsequent surgery and hospitalization.Fig. 1.: Proposed approach for breast reconstruction during the COVID-19 pandemic. DIEP, deep inferior epigastric perforator; SIEA, superficial inferior epigastric artery; SGAP, superior gluteal artery perforator; IGAP, inferior gluteal artery perforator; PAP, profunda artery perforator; TUG, transverse upper gracilis.There have been reports of thrombosis complications secondary to coronavirus infection.4 In this scenario, microsurgery procedures could be delayed until we have more and better knowledge, or at least new data and evidence of perioperative complications in elective microsurgery procedures. When the possibility of radiation was present, or after a shared decision-making approach, we opted for microsurgical free flap reconstruction, a tissue expander would be a better option to delay flap surgery at least 6 months, so we can offer a better safety profile. Offering immediate lymphatic reconstruction would offer higher benefits in these circumstances, to avoid new surgical procedures when possible, in addition to its established benefits.5 Nowadays, coronavirus infection considerations should be part of the shared decision-making process, and first consultation could be performed through virtual online options and three-dimensional models, as well as some follow-up consultations. Breast reconstruction should be considered in breast cancer patients even during the actual COVID-19 pandemic, and time will tell which is the best approach. For now, we should be proactive with caution. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Conventional CT versus Dedicated CT Angiography in DIEP Flap Planning: A Feasibility Study.

The deep inferior epigastric perforator (DIEP) flap is used with increasing frequency in post-mastectomy breast reconstruction. Preoperative mapping with CT angiography (CTa) is crucial in reducing surgical complications and optimizing surgical techniques. Our study’s goal was to investigate the accuracy of conventional CT (cCT), performed during disease staging, compared to CTa in preoperative DIEP flap planning. In this retrospective, single-center study, we enrolled patients scheduled for mastectomy and DIEP flap breast reconstruction, subjected to cCT within 24 months after CTa. We included 35 patients in the study. cCT accuracy was 95% (CI 0.80–0.98) in assessing the three largest perforators, 100% (CI 0.89–100) in assessing the dominant perforator, 93% (CI 0.71–0.94) in assessing the perforator intramuscular course, and 90.6% (CI 0.79–0.98) in assessing superficial venous communications. Superficial inferior epigastric artery (SIEA) caliber was recognized in 90% of cases (CI 0.84–0.99), with an excellent assessment of superficial inferior epigastric vein (SIEV) integrity (96% of cases, CI 0.84–0.99), and a lower accuracy in the evaluation of deep inferior epigastric artery (DIEA) branching type (85% of cases, CI 0.69–0.93). The mean X-ray dose spared would have been 788 ± 255 mGy/cm. Our study shows that cCT is as accurate as CTa in DIEP flap surgery planning.

The influence of venous system patterns on DIEP flap viability for breast reconstruction

A deep inferior epigastric artery perforator (DIEP) flap has unique variations in the anatomy of the vascular supply, and this idea has been adapted to the venous system. Venous system patterns, including connections between the superficial and deep inferior epigastric vein (SDC) or connections of the superficial inferior epigastric vein across the midline-crossing linking veins (MCLV), have gradually become recognized as a cause of fat necrosis and induration due to venous congestion. Therefore, it is important to select patients who are appropriate for transplantation by evaluating blood flow in the flap based on these patterns. The subjects were 52 consecutive patients who underwent DIEP flap breast reconstruction. Relationships of fat necrosis and induration of a transplanted flap and venous system patterns (presence of SDC on the contralateral side: cSDC or MCLV, direction and diameter of perforator vein) in the flap were investigated. Logistic regression and univariate and multivariate analyses were used to identify predictors of fat necrosis and induration of the flap. Fat necrosis and induration were detected in 17.4 and 34.8% of cases, respectively. These incidences were significantly linked to the absence of cSDC and MCLV patterns in the flap. Patients without a cSDC or MCLV pattern had harder fat tissue in Zone II, especially in the distal portion. These results suggest that the absence of a cSDC or MCLV pattern causes complications such as fat necrosis and induration in a transplanted flap. If neither pattern is detected before surgery, improvement of venous drainage is recommended.

Application of intraoperative indocyanine green angiography for detecting flap congestion in the use of free deep inferior epigastric perforator flaps for breast reconstruction.

The use of intraoperative indocyanine green (ICG) angiography has been well documented for confirmation of arterial perfusion in transferred free flaps. However, no previous report has yet focused on whether ICG angiography can be used to detect congestion in free flaps. The present report investigates the feasibility of ICG angiography for detecting flap congestion intraoperatively through illustrative cases. From September 2019 to September 2020, 65 consecutive female patients who underwent breast reconstructions using a free deep inferior epigastric perforator (DIEP) flap were enrolled in this study. Forty-eight patients with 52 DIEP flaps were eligible for the study after application of the exclusion criteria. ICG angiography was performed after elevation of the flap, after completion of the anastomoses, and after inset of the flap. In five cases (9.6%), an inadequate highlight was demonstrated with ICG angiography performed after flap elevation. All such cases were deemed congestive since robust bleeding was observed with the prick test. ICG angiography demonstrated sufficient highlight of the flap after removal of the clamp on the superficial inferior epigastric vein. In two cases (4.2%), kinking of the pedicle vein of the DIEP flap was found with ICG angiography performed after inset of the flap. In both cases, the pedicle and the flap were reinset. All flaps survived completely postoperatively. ICG angiography can detect flap congestion, and the proposed 3-step protocol is useful for the prevention of postoperative complications.

A Case-control Analysis of the Knight's Move Technique in a Chicken Wing Microsurgery Model: Video Article.

A Case-control Analysis of the Knight's Move Technique in a Chicken Wing Microsurgery Model: Video Article.

ZNF667 attenuates leukocyte-endothelial adhesion via downregulation of P-selectin in skin flap following remote limb ischemic preconditioning.

We assessed the effects and potential mechanism of romote ischemic preconditioning (RIPC) on leukocytes-endothelium cell adhesion in the flap microvessel after ischemia-reperfusion (I/R) injury. Eight hours after reperfusion, edema and intravascular leukocyte aggregation were reduced and microvessels were more obvious in the group with superficial inferior epigastric artery (SIEA) perforator flap (SIEA-flap) subjected to RIPC than in the I/R group. Zinc finger protein 667 (ZNF667) was significantly increased but P-selectin was decreased in the flaps subjected to RIPC, compared to those in the I/R group. The low expression of P-selectin was associated with ZNF667 expression and activation in human dermal microvascular endothelial cells in response to hypoxic preconditioning. ZNF667 bound to the P-selectin promoter region, suppressing its transcription through a special core sequence. The ablation of P-selectin by small interfering RNA effectively prevented the leukocytes-endothelium cell adhesion effect of ZNF667-knockdown. ZNF667 upregulation attenuates leukocyte-endothelial cell adhesion by negatively regulating the expression of P-selectin in SIEA-flap subjected to RIPC.

Application of superficial inferior epigastric artery flaps to repair oral and maxillofacial defects with the aid of digital three-dimensional reconstruction technique

Objective: To explore the application value of digital three-dimensional(3D) reconstruction technology in the repair of oral and maxillofacial defects with superficial inferior epigastric artery (SIEA) flap. Methods: Twelve cases of oral cancer patients, including 8 males and 4 females; aged (57.4±12.6) years, were selected from the Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Bengbu Medical College from January 2018 to October 2019 and were proposed to repair with SIEA flap. There were 10 cases of squamous cell carcinoma, one case of adenoid cystic carcinoma and 1 case of mucinous epidermal carcinoma. The data were imported into AW4.7 software for post-processing. The left or right dominant donor area was selected to clarify the origin, diameter, alignment, and location of penetration point of the flap blood supply, and digital 3D reconstruction technology was used to guide the flap preoperative design. Results: Eleven cases were repaired by SIEA flap in 12 patients, one case was repaired by superficial iliac artery flap because the source artery was undiscovered, one case had venous vascular crisis after surgery, and the rest of the flap survived. In 11 patients repaired with SIEA flap, there was no significant difference between the preoperative SIEA diameter measured by CTA [(1.0±0.3) mm] and the actual measured value [(1.1±0.3) mm] (P>0.05). The follow-up was 6 to 12 months, with an average of 10 months, and the donor-receiver areas were all healed in phase Ⅰ. No obvious complications occurred, and the abdominal scar was hidden. Conclusions: In the SIEA flap repair oral and maxillofacial defect reconstruction surgery, the use of digital 3D reconstruction technology can objectively reflect the diameter and the location of the superficial artery of the abdominal wall before surgery, effectively reduce the difficulty and risk of flap surgery.

Use of a combined SIEA and SCIP based double pedicled abdominal flap for breast reconstruction.

Recently, the deep inferior epigastric perforator (DIEP) flap has become the gold standard for breast reconstruction, but it has some drawbacks such as abdominal bulging and hernia. To overcome these disadvantages, the superficial inferior epigastric artery perforator (SIEA) flap is used as an alternative option, but it has another problem, namely limited vascular territory and risk of vascular thrombosis. To solve these problems, we introduced our new technique, a combined SIEA and superficial circumflex iliac artery perforator (SCIP) based double pedicled abdominal flap. In this report, we present our experience of using this technique. The SIEA and SCIP based double pedicled abdominal flap was used in five patients who wanted to have unilateral breast reconstruction after a mastectomy due to breast cancer. The average age was 48.2 (range 38-56) years, and the average BMI was 24.4 (range 19.2-31.4). The SIEA and SCIP based double pedicled abdominal flap was designed as a modified DIEP flap, and all flaps were placed in the vertical setting. The flap pedicles had two different vascular supplies, SIEA and SCIA, and the drainage systems, SIEV and SCIV, anastomosed to the internal mammary artery and vein in all cases. The harvested SIEA and SCIP based double pedicled abdominal flaps were a median volume of 925 g (range 452-1570 g) and average size of 491 cm2 (range 440-611 cm2 ). The average reconstructive time was 7:41 (range 6:31-9:17). In four out of the five cases, the SIEA and SCIA joined together to make a common pedicle artery trunk, and its average size was 1.08 mm. Four out of the five cases had a wide vascular territory crossing the abdominal midline as shown by ICG angiography. One case showed ICG fluorescence for the hemi-side of the abdominal flap. Postoperative course was uneventful, and there were no major perioperative complications, which need extra surgical procedures. Follow-up period averaged 273 days (range 194-312 days). The SIEA and SCIP based double pedicled abdominal flap showed viable flap territory across the midline in all cases. The SIEA and SCIP based double pedicled abdominal flap might be another ideal option for breast reconstruction, when appropriate SIEA and SCIA pedicles are identified, and an adequate ICG fluorescence is obtained for the size of flap needed.

Engineering of axially vascularized bone tissue using natural coral scaffold and osteogenic bone marrow mesenchymal stem cell sheets

IntroductionBlood supply remains one of the obstacles to large bone tissue engineering. This study aimed to generate vascularized bone tissue by inducing axial vascularization into a construct combining natural coral scaffold and a bone marrow mesenchymal stem cells (BMSCs) sheet. Material and methodsIsolated BMSCs were cultured to form an osteogenic cell sheet using a continuous culture method. Natural coral scaffolds were prepared into customized shape with a cylinder of 20 mm length, 8 mm in outer diameter and 5 mm in inner diameter. Then, the freed superficial inferior epigastric vessel of rabbits was first wrapped with a cell sheet, and then inserted into the central passage of the scaffold, after being wrapped with another cell sheet, the complexes were implanted subcutaneously into a rabbit groin area. In contrast, the sheet-scaffold construct that implanted into groin subcutaneous area of the other side of the same rabbit with the distal end of the blood vessel was ligated, which was considered as control. New bone and vascularization formation were evaluated at 12 weeks postoperatively. ResultsThe volume of new bone formation and amount of capillary infiltration in the vascular circulation group were significantly greater than that in the vascular ligation group, which suggested that insertion of axial vessels could significantly promote angiogenesis and osteogenesis of the tissue-engineered bone. ConclusionsThese findings indicate that inserting an arteriovenous bundle into the constructs of mesenchymal stem cell sheet and coral has great potential for clinical applications to repair large bone defects.

Autologous Breast Reconstruction Trends in the United States: Using the Nationwide Inpatient Sample Database.

Autologous tissue is the criterion standard in breast reconstruction, but traditionally has been used as a secondary option after implant-based options because of reduced reimbursement relative to effort and required additional technical skill. We intended to evaluate the overall frequency and trends of autologous breast reconstruction (ABR), the trends of ABR in teaching versus nonteaching hospitals and the trends of ABR in different hospital regions in the United States. Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed ABR from 2009 to 2016 in the United States. A total of 146,185 patients underwent ABR during this period. The overall rate of ABR increased 112%, from 26.6% to 56.5%. The majority of ABR were delayed reconstructions (62.3%), which increased gradually from 54.9% to 80% during the study period. The overall frequency of flaps included the deep inferior epigastric perforator (32.1%), latissimus dorsi myocutaneous (28.4%), free transvers rectus abdominus myocutaneous (15.9%), pedicled transvers rectus abdominus myocutaneous flap (14.5%), gluteal artery perforator (0.6%), superficial inferior epigastric artery (0.6%), and unspecified-ABR (7.2%). Most ABRs were performed in teaching hospitals (78.6%) versus nonteaching hospitals (21.4%). The teaching hospitals' ABR rate increased from 70.5% to 88.7%. The greatest proportion of ABRs were performed in the south (39.6%) followed by northeast (23.0%), midwest (18.9%), and west (18.5%). The deep inferior epigastric perforator flap has become the predominant ABR method in the United States. In addition to more delayed reconstructions being performed in recent years, ABR rates are increasing overall and shifting from pedicled flaps to free flaps.

Microcomputed analysis of nerve angioarchitecture after combined stem cell delivery and surgical angiogenesis to nerve allograft

A detailed three-dimensional (3D) evaluation of microvasculature is evolving to be a powerful tool, providing mechanistic understanding of angiomodulating strategies. The aim of this study was to evaluate the microvascular architecture of nerve allografts after combined stem cell delivery and surgical angiogenesis in a rat sciatic nerve defect model. In 25 Lewis rats, sciatic nerve gaps were repaired with (i) autografts, (ii) allografts, (iii) allografts wrapped in a pedicled superficial inferior epigastric artery fascia (SIEF) flap to provide surgical angiogenesis, combined with (iv) undifferentiated mesenchymal stem cells (MSC) and (v) MSCs differentiated into Schwann cell-like cells. At two weeks, vascular volume was measured using microcomputed tomography, and percentage and volume of vessels at different diameters were evaluated and compared with controls. The vascular volume was significantly greatest in allografts treated with undifferentiated MSCs and surgical angiogenesis combined as compared to all experimental groups (P<0.01 as compared to autografts, P<0.0001 to allografts, and P<0.05 to SIEF and SIEF combined with differentiated MSCs, respectively). Volume and diameters of vessel segments in nerve allografts were enhanced by surgical angiogenesis. These distributions were further improved when surgical angiogenesis was combined with stem cells, with greatest increase found when combined with undifferentiated MSCs. The interaction between vascularity and stem cells remains complex, however, this study provides some insight into its synergistic mechanisms. The combination of surgical angiogenesis with undifferentiated MSCs specifically, results in the greatest increase in revascularization, size of vessels, and stimulation of vessels to reach the middle longitudinal third of the nerve allograft.

Micro-Rheological Changes of Red Blood Cells in the Presence of an Arterio-Venous Fistula or a Loop-Shaped Venous Graft in the Rat.

Introduction: In case of kidney failure, hemodialysis is the primary kidney replacement technique. Several vascular access methods used for the therapy, one of which is the arterio-venous fistula (AVF). In the AVF, the blood flow is altered, which can elevate the mechanical stress on the red blood cells (RBCs). This can affect the RBC hemorheological properties, and it can further cause systemic changes. To lower the turbulence and shear stress, we performed a loop-shaped arterio-arterial venous interposition graft (loop-shaped graft) to compare its effect to the conventional AVF.Materials and Methods: Thirty male Wistar were used (permission registration Nr.: 25/2016/UDCAW). The animals were randomly divided into sham-operated, AVF, and loop groups (n = 10/each). The superficial inferior epigastric vein (SIEV) was used to create the AVF and the loop-shaped graft. Blood samples were taken before/after the surgery and at the 1st, 3rd, and 5th postoperative weeks. We measured hemorhelogical, hematological, and blood gas parameters. The microcirculation of the hind limbs was also monitored using Laser Doppler fluxmetry.Results: Hematocrit, RBC count, and hemoglobin decreased by the 1st postoperative week. The erythrocyte aggregation values significantly increased in the fistula group by the 5th week (6.43 ± 2.31 vs. 13.60; p < 0.0001; vs. before operation). At the postoperative 1st week in the loop group, the values showed a significant decrease in RBC deformability. During the maturation period, dominantly at the 5th week, all values were normalized. The operated hind limb’s skin microcirculation significantly increased in the sham and loop group by the 1st week (39 ± 10.57 vs. 73.93 ± 1.97 BFU, p < 0.01). This increase wasn’t observed in the fistula group probably due to a steal-effect.Conclusion: Unlike in the loop group, in the presence of the fistula, several rheological parameters have changed. The loop-shaped graft had only minimal impact on micro-rheological parameters.

Pedicled Split Hypogastric Flap (Superficial Inferior Epigastric Artery flap): A New Technique for Coverage of Nonadjacent Defects in the Hand.

Flap coverage of soft tissue defects on both surfaces of the hand or of nonadjacent defects in the hand is a challenge. Two flaps are needed or if a single flap is used, the intervening normal area or part of the flap must be deepithelialized or the flap tunneled under the normal bridge segment. We are presenting a new technique whereby the hypogastric flap based on the superficial inferior epigastric artery is split into 2 components for the coverage of such defects. The hypogastric flap is separated into a cutaneous component and an adipofascial component at the level of Scarpa fascia. The flaps are separated almost to the base to increase mobility. Now it can be used to cover 2 defects separated by 5 to 7 cm or for defects in the dorsum and the palm. We have used it in 3 patients, in 2 for the coverage of palmar and dorsal aspect of the hand and in one for the coverage of nonadjacent defects on the dorsum of the hand and distal forearm after postburn contracture release. We achieved good results with no flap-related complications.

The Superficial Inferior Epigastric Artery Based Abdominal Flap for Reconstruction of Extensive Defects of the Hand and Forearm: A Modified Design With Primary Closure of the Donor Site.

The reconstruction of the hand and forearm targets the restoration of their function and aesthetic appearance. Inferiorly based abdominal flaps are reliable and versatile flaps that can cover large defects of the forearm and hand. Here we present a modified abdominal flap design based exclusively on the superficial inferior epigastric artery (SIEA) to reconstruct the hand and forearm's extensive defects. The donor site is closed primarily. This is a retrospective study of the patients who underwent reconstruction of hand and forearm defects with SIEA flap from 2006 to 2018. The flap was designed on the ipsilateral hemiabdomen with a narrow pedicle based on the SIEA. We describe the anatomical basis and the outcomes of SIEA flap for reconstruction of the hand and forearm's extensive defects. Forty-eight soft tissue defects of the hand and forearm were reconstructed with the SIEA-based abdominal flap. Twenty-nine (60.41%) dorsal defects, 4 (8.33%) volar defects, 4 (8.33%) circumferential defects, 6 (12.5%) hand amputation stump, and 5 (10.41%) finger and thumb defects were covered using the SIEA flap. Forty-seven (97.91%) flaps had complete survival, whereas 1 (2.08%) flap had distal necrosis at the time of division. One (2.08%) flap had marginal necrosis, and 1 (2.08%) flap had distal necrosis after the division. The donor site was closed primarily in all patients. One (2.08%) patient had wound dehiscence at the abdominal donor site. All flaps gave excellent coverage with a satisfactory contour. Abdominal flap based on SIEA is a safe, reliable, and versatile flap for the reconstruction of extensive soft-tissue defects of the hand and forearm. An ability to provide a large amount of skin and soft tissue and the abdominal donor site's primary closure make it a favorable option for upper limb reconstruction in regions with limited resources and technical expertise.

Differences of the midline-crossing venous drainage pattern in supraumbilical and infraumbilical regions: Angiographic study using fresh cadavers.

Current clinical and anatomical studies show that the venous problem associated with the deep inferior epigastric perforator flap results from poor midline-crossing. We examined the venous anatomy of the infraumbilical midline area and the dynamic venous flow of the deep inferior epigastric perforator flap in nine fresh cadavers. All nine abdominal specimens were harvested between the subcostal margin and the groin crease. Two specimens were used to analyze the abdominal venous anatomy, one of which was divided into two hemi-abdominal specimens. The remaining seven specimens were harvested as deep inferior epigastric perforator flaps with one major paraumbilical perforator. Venous cannulation and serial angiographic agent injection were performed in several conditions. Each specimen was radiographed using a soft X-ray system. For additional information, computed tomography (CT) angiography-visualized superficial inferior epigastric veins (SIEVs) and the supraumbilical branch were analyzed. We noted that the venous drainage between the bilateral SIEVs was easier to configure in the supraumbilical area than in the infraumbilical area. Only one to two short polygonal venous networks connect the bilateral superficial inferior epigastric veins in the supraumbilical area; however, long and multiple polygonal venous networks connect the bilateral superficial inferior epigastric veins in the infraumbilical area, which could be a predisposing factor for venous congestion. The mean distance from the umbilicus upper border to evident supraumbilical midline crossover was 18.39±4.03 mm (range: 10.10–28.49) in CT angiograms. In cadaver specimens, the mean distance was 10.87±4.85 mm (range: 4.6–18.9). Supraumbilical midline crossover was more favorable than infraumbilical midline crossover in venous flow.

Application of contrast-enhanced ultrasound-assisted superficial inferior epigastric artery perforator flap to repair oral and maxillofacial defects

To investigate the application value of contrast-enhanced ultrasound (CEUS) technique to assist the repair of oral and maxillofacial defects by superficial inferior epigastric artery perforator flap. Sixteen oral cancer patients, 10 males and 6 females, who were to undergo superficial inferior epigastric artery perforator flap repair between June 2018 and February 2020, were selected, with an average age of 55.8 years (range, 24-77 years). There were 13 cases of squamous cell carcinoma, 2 cases of adenoid cystic carcinoma, and 1 case of mucinous epidermis-like carcinoma. The color Doppler ultrasound (CDUS) and CEUS were used to screen the superficial inferior epigastric artery, assisted in the design of the flap, and compared it with the actual intraoperative exploration. The sensitivity, specificity, positive predictive value, and negative predictive value of CEUS and CDUS examinations were analyzed. Fourteen of 16 patients were repaired with superficial inferior epigastric artery perforator flap, and 2 patients were repaired with superficial iliac artery flap because the source artery was not found. After surgery, regular follow-up was performed to check for disease recurrence and metastasis and to evaluate the appearance of the patien's donor area, the recovery of transoral feeding function, and the presence of complications. Comparison of preoperative CDUS and CEUS findings and intraoperative exploration showed that CEUS had 100% sensitivity, specificity, positive predictive value, and negative predictive value for vascular exploration of the superficial inferior epigastric artery perforator flap, compared with 57%, 100%, 100%, and 25% for CDUS. The preoperative CDUS identified 25 penetrating vessels in 14 cases repaired with superficial inferior epigastric artery flaps. All vessel signals were enhanced by CEUS enhancement, and an additional 11 penetrating vessels were identified confirmed intraoperatively. The preoperative CEUS measurements of the initial diameter of superficial arteries in the abdominal wall were significantly higher than both CDUS and intraoperative measurements ( P<0.05); the difference in peak systolic velocity between CEUS and CDUS measurements was significant ( t=3.708, P=0.003). One case of superficial epigastric artery perforator flap developed venous embolism crisis at 48 hours after operation, the wound healing delayed. The other incisions in donor sites healed by first intention. All the patients were followed up 3-12 months, with an average of 8 months. No recurrence or metastasis appeared during the follow-up. There was no serious complications such as abdominal wall hernia, the location of abdominal scarring was hidden, and transoral feeding was resumed. The superficial inferior epigastric artery perforator flap with small injury in supply area and hidden scar location is a better choice for repairing oral and maxillofacial defects. The use of CEUS technique to assist the preoperative design of the superficial inferior epigastric artery perforator flap has good feasibility and high accuracy.

Descriptive anatomy of the inferior epigastric, subscapular and internal thoracic vascular pedicles in three domestic mammals: A comparative study

The descriptive anatomy of the inferior epigastric, subscapular and internal thoracic vascular pedicles of domestic animals is not fully known. Improvement of our knowledge in this field could lead to better development of animal models for both pedagogical purposes and surgical experimentation. The objective of this comparative study was to describe the descriptive anatomy of the inferior epigastric, subscapular and internal thoracic pedicles in three domestic mammals commonly used as animal models for experimentation. Our study focuses on the anatomical description of these vascular pedicles in the rat (Rattus norvegicus) (n=1), the rabbit (Oryctolagus cuniculus) (n=1) and the pig (Sus scrofa domesticus) (n=1). A comparative and analytical study of these vessels (origin, path, caliber, termination) with those of humans was carried out. The superficial inferior epigastric vascular pedicles have been identified only in rats and pigs. The deep inferior epigastric, subscapular and internal thoracic pedicles were identified in the three mammals studied. No perforator vessels for the subcutaneous tissue and skin were identify from the deep inferior epigastric pedicles. The anatomical characteristics (origin, path, termination) of these vascular pedicles in rabbits seems to be the closest to that of humans. However the caliber of these vessels is around a millimeter compared to a 2.0-3.0mm in humans. This comparative study allowed us to identify and better characterize the morphological characteristics of these vascular pedicles in three domestic mammals, a step prior improving the development of animal models intended for pedagogical or experimental purposes in the field of microsurgical free flaps.