Vascular Pedicle Research Articles

The vascular supply to the lateral compartment of the leg with emphasis on fibular flap harvesting.

The aim of this study is to determine the exact locations of vascular pedicles that supply the fibularis longus and brevis, to identify the morphometric features of those vessels in the lateral compartment of the leg, and to indicate the branching points of the pedicles from the main arteries. The popliteal arteries of 40 lower limbs from 20 adult cadavers (12 males, 8 females) were bilaterally injected with colored latex. After dissection, the branches of the arteries were identified and counted. The distances between the apex of the head of the fibula and the branching points of the anterior tibial, fibular, and posterior tibial arteries supplying the fibularis longus and brevis muscles were measured. In all cases, a single artery coursing in the lateral compartment of the leg was identified; it was a branch of the anterior tibial artery and it supplied the proximal and middle thirds of the fibular muscles anteriorly. The mean distance between the origin of this artery and the apex of the fibular head was 8.65cm. Its mean length was 10.9cm and the mean number of its branches was 5.1. In all specimens, the fibular artery supplied the proximal and distal portions of the fibular muscles posteriorly. This study provides a detailed description of the morphometric properties and branching patterns of the axial pedicle of the anterior tibial artery, which runs longitudinally in the lateral compartment and supplies the fibularis longus and fibularis brevis muscles. We propose naming the pedicle of anterior tibial artery the lateral fibular artery. If this nomenclature is accepted, the fibular artery could be renamed the "posterior fibular artery".

Adamantinoma of the Tibial Shaft Treated with Intercalary Reconstruction Using Ipsilateral Pedicled Vascularized Fibular Graft and Screw Fixation

Adamantinoma of the Tibial Shaft Treated with Intercalary Reconstruction Using Ipsilateral Pedicled Vascularized Fibular Graft and Screw Fixation

Kidney Allograft Torsion After Simultaneous Pancreas Kidney Transplantation: Case Report and Review of Literature

Kidney allograft torsion (KAT) is a rare but critical complication of kidney transplantation that can lead to graft loss due to acute ischemia. This report presents a case of KAT resulting in graft loss 9 months following intraperitoneal simultaneous pancreas and kidney (SPK) transplant and reviews previous reports to identify potential high‐risk features. A 38‐year‐old female with end‐stage renal disease secondary to Type 1 diabetes mellitus underwent an intraperitoneal enteric drained SPK transplant. Nine months post‐transplantation, she presented with nausea, vomiting, severe abdominal pain, decreased urine output, and diarrhea. An ultrasound showed moderate hydronephrosis and no blood flow to the renal hilum. Exploratory laparotomy revealed a necrotic renal allograft twisted 360° counterclockwise on its vascular pedicles. Despite detorsion, the graft showed no signs of viability, necessitating transplant nephrectomy. This case highlights the rarity and severity of KAT, particularly in intraperitoneal kidney transplants. The patient’s low body mass index (BMI) (23.4 kg/m2), female sex (wider pelvis), and minimal intra‐abdominal adhesions may have contributed to increased graft mobility, predisposing to KAT. Other potential risk factors include elongated vascular pedicle and immunosuppression‐related reduced adhesion formation. The nonspecific presentation of KAT emphasizes the need for high clinical suspicion and prompt ultrasonographic evaluation in cases of graft abnormalities. This report underscores the importance of considering patient‐ and graft‐specific factors in assessing KAT risk and the critical nature of early detection and intervention to prevent graft loss.

Indocyanine Green Angiography for Real‐time Evaluation of Nasoseptal Flap Vascularity and Perfusion

ObjectivesTo investigate the characteristics of the vascular pedicle of the nasoseptal flap (NSF) and its perfusion patterns using intraoperative indocyanine green (ICG) angiography during endoscopic skull base surgery (ESBS), and examine the correlation between ICG perfusion patterns and clinical outcomes, including postoperative cerebrospinal fluid (CSF) leak and flap necrosis.MethodsThis study enrolled patients undergoing ESBS between January 2017 and December 2021. Intraoperative ICG angiography was performed to visualize the arterial supply of the nasal septum and evaluate NSF perfusion. Postoperative CT scans and clinical follow‐ups were conducted to assess flap outcomes.ResultsA total of 126 patients were included in the study. The posterior septal artery (PSA) was most commonly identified in the middle third of the sphenoidal rostrum (63.5% right, 60.3% left). Three branching patterns were observed: single‐branch (58.7% right, 64.3% left), double‐branch (12.7% right, 11.1% left), and reticular‐branch (26.6% right, 24.6% left). Among 72 patients who underwent NSF placement, ICG angiography showed full enhancement in 37 patients (51.4%), partial enhancement in 27 patients (37.5%), and no enhancement in eight patients (11.1%). Postoperative CSF leak occurred in eight patients (11.1%), with no significant correlation to ICG enhancement patterns (p = 0.07). Flap necrosis occurred in five patients (6.9%), all of whom had shown no ICG enhancement beyond the pedicle (p < 0.01).ConclusionsICG angiography is a valuable tool for visualizing the vascular supply of NSF during ESBS. While it does not correlate with postoperative CSF leak, ICG enhancement pattern showed a significant association with flap necrosis. This technique may contribute to improved surgical outcomes and reduced complications in NSF reconstructions.Level of Evidence3 Laryngoscope, 2024

The IMAP and MICAP Flaps for Autologous Breast Reconstruction: An Anatomic, Clinical, and Outcome Study.

Local flaps for breast reconstruction are becoming recognized as a viable alternative to remote flaps. The purpose of this manuscript is to describe the anatomy and clinical outcomes using the internal mammary artery perforators and the lateral intercostal artery perforator flaps for breast reconstruction. Twelve cadaveric specimens were injected with colored latex and dissected to demonstrate the medial perforators of the 5th intercostal space. Twenty-two patients had partial or total breast reconstruction using the internal mammary artery perforator flaps that was combined with the lateral intercostal artery perforator flap in 4 patients. The study was performed at the Hospital de Clinicas Jose de San Martin that is affiliated with the Universidad de Buenos Aires in Argentina between March 2018 -December 2023. Outcomes were based on clinical evaluation and statistical analysis. Patient satisfaction was assessed on a 5-point Likert scale based on whether they were clothed or unclothed. All flaps survived without any evidence of partial flap necrosis. There were no major complications (total flap loss, partial necrosis); however, fat necrosis was demonstrated in two patients. Minor complications included a small hematoma and a minor wound dehiscence. Patient satisfaction was rated as very good or excellent in 100% of women when clothed and rated as good to very good in 93.3% of women when unclothed. Submammary perforator flaps can be raised on numerous vascular pedicles. This study has demonstrated that the internal mammary and the lateral intercostal can be successfully used for partial or total breast reconstruction in properly selected patients.

Angiographic Observation of the Perforators of Thoracodorsal Artery and Application of the Perforator Flaps in Repairing Adjacent Wounds

Objective: The thoracodorsal artery perforator flap has not been widely used in clinical practice partly due to a lack of imaging evidence. The authors aim to investigate the types of thoracic dorsal artery perforators through angiography and provide our experiences in the utilization of thoracic dorsal artery perforator flaps to repair adjacent wounds. Methods: This study was divided into two parts. The first part was an angiography of the thoracodorsal artery in 12 patients based on DSA and CTA images from January 2015 to December 2023. The branches and perforators of the thoracodorsal artery were observed and classified. The second part study, between January 2019 and December 2023, illustrated the clinical application of thoracodorsal artery perforator flap in repairing neighboring wounds in 10 cases where a small area of muscular vascular pedicle was preserved with oblique branch of thoracodorsal artery trunk dissected to extend the pedicle. The donor area of the flap was closed primarily. The patients were followed up to evaluate the functional recovery of the shoulder joint after operation. Results: The perforators of thoracodorsal artery were classified into 2 types based on the number and diameter: type I, the dominant perforating type (1–2 dominant perforators plus varying numbers of tiny perforators); and type II, the capillary perforating type (a larger number of tiny perforators without dominant perforators). The diameter of the dominant perforator is >0.5 mm, while the diameter of the capillary perforators is <0.5 mm. In the first part of the study, there were 8 cases of dominant perforating type and 4 cases of capillary perforating type. In the second part of the study, 10 cases of thoracodorsal artery perforator flaps were applied to repair the chest wall (3 cases), the back (1 case), the axilla (2 cases), the shoulder (2 cases) and the upper arm (2 cases). All the flaps fully survived with no complications, such as hematoma and seroma in the donor area. The function of the shoulder joint was not affected in these patients. Conclusions: The angiography showed that thoracodorsal artery perforators could be categorized into 2 types, namely the dominant perforators and capillary perforators. The thoracodorsal artery perforator flap with a small area of muscular vascular pedicle can be harvested with blood supply from both types of perforators. With reliable blood supply, flexible selection of tissue volume and minimal muscle injury, it becomes a good choice for repairing wounds on the thoracic-dorsal-shoulder area.

The Whirlpool Sign in Pediatric Body Imaging: Diagnostic Value and Clinical Implications

The whirlpool sign denotes twisting of the vascular pedicle of a nearby organ, suggesting an emergency that needs urgent attention and prompt treatment. Although the whirlpool sign does not determine the underlying cause of torsion, it is most often specific for torsion, which is the driving force for management in most scenarios. A mesenteric whirlpool indicates midgut malrotation and volvulus, while in the adnexa it denotes ovarian torsion, and finally a scrotal whirlpool indicates testicular torsion. Thus, it is important to recognize such signs, mostly on ultrasound, to avoid the downsides of delayed recognition and improper treatment.

Torsion of the wandering spleen with intestinal obstruction.

Wandering spleen is a relatively rare condition and may be complicated by intestinal obstruction or abnormal intestinal rotation. Herein, we report a case where these three conditions appeared concomitantly. An 18-year-old woman with an intellectual disability was admitted to the hospital because of vomiting and fever. The patient's abdomen was distended. Computed tomography revealed a dilated small intestine, a swollen spleen located in the lower abdomen, as well as twisting and swirling of the splenic artery and vein. The patient was diagnosed with torsion of the wandering spleen and emergency surgery was performed. The vascular pedicle was found to be rotated 900° clockwise, and a markedly enlarged spleen was observed in the lower abdomen. When the splenic torsion was released, the pulsation of the splenic artery was well palpated, suggesting that the spleen could be preserved. Additionally, the sigmoid colon to the cecum was not fixed to the retroperitoneum. Dilatation of the small intestine was observed, but there were no findings of intestinal tract necrosis. Splenic torsion is part of the differential diagnosis for acute abdomen. Familiarity with embryology and anatomy is necessary to select the appropriate surgical technique.

An Anomalous Middle Thyroid Vein: A Case Report and a Short Review of the Vascular Anatomy of Thyroid Gland

The thyroid gland is an endocrine organ in the anterior neck having a complex vascular network comprising of paired arteries and veins. Variations in this anatomy are significant for surgical procedures involving the thyroid and parathyroid glands. A 40-year-old euthyroid female who underwent total thyroidectomy for a multinodular goiter, was found to have a rare anomalous middle thyroid vein which originated from the upper pole of the right lobe, separate yet alongside the superior pole vascular pedicle. This was in stark contrast to its normal anatomy where the vein arises from the middle portion of the lobe and traverse laterally in front of the common carotid artery to terminate in the internal jugular vein. Understanding such variations is critical in order to avoid complications during surgical interventions.

Myopericytoma of the hand.

Myopericytoma is a rare benign smooth-muscle cell neoplasm of the subcutaneous soft tissues that is primarily found in young adults with a male predominance. We present the clinical, radiologic, and histopathologic features of a longstanding myopericytoma of the hand. We emphasize the features that help the radiologist and pathologist to accurately characterize this entity. Radiologic evaluation, particularly MRI, plays a crucial role in differentiating myopericytoma from other soft tissue masses. Characteristic MR features include a well-demarcated lesion with intense post-contrast enhancement, isointensity to muscle on T1-weighted imaging, and hyperintensity on T2-weighted imaging, often with a central vascular pedicle. Histopathologic examination reveals a concentric perivascular growth pattern, which helps to distinguish myopericytoma from other soft tissue tumors. Immunohistochemically, these myoid cell neoplasms stain positive for alpha-smooth muscle actin and h-caldesmon, lack nuclear atypia, and are not highly proliferative (relatively low Ki-67 index and very low mitotic activity). The vast majority stain negative for desmin and CD34. Treatment typically involves complete surgical resection, with excellent prognosis and rare recurrence. Despite its rarity, awareness of this entity is important for clinicians who encounter soft tissue masses of the extremities.

"Dangling choroid" with contralateral glomus displacement and ischemic torsion in congenital hydrocephalus: illustrative case.

"Dangling choroid" is a prenatal sonographic marker of ventriculomegaly that measures the angle of choroid plexus (ChP) displacement in the lateral ventricle. To the authors' knowledge, postnatal sequelae related to this pathology, besides hydrocephalus, have never been reported. A female fetus was diagnosed with bilateral ventriculomegaly. Postnatally, the patient was diagnosed with hydrocephalus and macrocephaly secondary to aqueductal stenosis and underwent endoscopic third ventriculostomy with ChP cauterization. Intraoperatively, the septum pellucidum was incomplete, and the right-sided ChP glomus was contralaterally displaced and entangled with the left, with evidence of ischemic torsion and hemorrhage. In this case of an ischemic ChP secondary to transventricular displacement of the glomus, at least two biomechanical events are relevant. First, the choroid fissure and velum interpositum can be thinned in the setting of ventriculomegaly. Second, stretching and perforation of the septum pellucidum can occur. Both changes can increase the mobility of a dangling choroid, occasionally leading to entanglement of the vascular pedicles. Preoperative recognition of this complication can help optimize surgical planning, e.g., using flexible endoscopy to facilitate complete ChP cauterization and changing the surgical approach if the ChP has been displaced. https://thejns.org/doi/10.3171/CASE24505.

Management of Delayed Vascular Occlusion in Free Flap Breast Reconstruction: A Systematic Review of Literature and Case Report.

Free flap surgery is a reliable and safe procedure for breast reconstruction. The survival of free flaps depends on their vascular pedicle initially, but neovascularization can sustain their blood supply after a while. Management of late pedicle occlusion in free flap breast reconstruction and potential implications of late pedicle occlusion on the transferred tissue are controversial. We systematically reviewed current literature focusing on articles that reported on late pedicle occlusion in free flaps for breast reconstruction. We aimed to analyze incidences of late pedicle occlusion, the existing evidence for the most appropriate management strategy for late pedicle occlusion, and its implications on overall outcomes. In support of the review, we present a clinical case of a salvage of a deep inferior epigastric artery perforator flap following late arterial thrombosis 12 days postoperatively. The literature is limited to a few case reports on pedicle occlusion in free flap breast reconstruction and a few heterogeneous retrospective reviews reporting on late pedicle occlusion in general. Despite the heterogeneity of articles and approaches to salvage flaps with late pedicle occlusion, we found no convincing evidence that surgery is the best choice to salvage flaps in breast reconstruction that appear to have late pedicle occlusion. Our case demonstrates that a conservative approach may be justified more than initially deemed necessary. Late pedicle occlusion is a rare but serious event in free flap breast reconstruction. Surgery does not seem to be the most appropriate approach in every case. Decisions should be based on clinical dynamics and imaging findings such as indocyanine-green angiography. A carefully carried out conservative approach may lead to flap salvage.

An unexpected surprise: splenic volvulus

BackgroundSplenic volvulus is a rare cause of acute and chronic abdominal pain. This condition is determined by an insufficiency or absence of the ligamentous attachments, a condition known as “wandering spleen” that causes a hypermobility of the spleen. Wandering spleen could be congenital or acquired and is more frequent in women of reproductive age and in children. Symptoms may remain limited or absent for long periods of time, but complications can occur due to the torsion of the splenic vascular pedicle, resulting in symptoms ranging from an incidental finding to an acute abdomen derived from ischemic necrosis of the spleen.Case presentationA 19-year-old male, admitted for abdominal pain and general discomfort. Considering the objective examination, further diagnostic tests were requested. Computed tomography (CT) revealed a chronic venous thrombosis of the splenic vein, hypoperfusion and malposition of the spleen, peritoneal effusion and stretching of structures in the left upper abdominal quadrant. These are strongly suspicious signs of splenic volvulus.ConclusionThe diagnosis of this rare condition can be challenging because of the variability of its symptoms and its capacity of mimicking other pathologies. Suggestive signs should be recognized in order to ensure a timely diagnosis and to choose the optimal strategy of treatment.

Nasoseptal Flap Reuse for Reconstruction in Revision Endoscopic Skull Base Surgery

Abstract Introduction The nasoseptal flap (NSF) is the “workhorse” for reconstruction in endoscopic skull base surgery. It creates a reliable, watertight closure to prevent cerebrospinal fluid (CSF) leaks. The flap's robust vascular pedicle allows for it to be taken down and reused in subsequent reconstructive surgeries if needed. Previous literature has demonstrated successful reuse of the flap up to 24 months after initial surgery. The present study analyzes a cohort of patients with NSFs that were reused up to 12 years following the initial surgery. Methods A retrospective analysis was performed on patients who underwent revision endoscopic skull base surgery for recurrent tumor at a tertiary academic skull base center. Patient demographics, tumor type, length of time between first and second surgery, and outcomes were evaluated. Results A total of 15 patients were identified between 2012 and 2022 who underwent revision endoscopic skull base surgery with previous NSFs that were reused for reconstruction. The time interval between surgeries ranged from 9 months to 12 years. There were 12 pituitary adenomas, 2 Rathke's cleft cysts, and 1 craniopharyngioma. One patient developed a CSF leak 5 days postoperatively, which was repaired with an abdominal fat graft, synthetic dural substitute, and a middle turbinate flap. The operative technique for the take-down and reuse of the NSF will be demonstrated. Conclusion The NSF can be taken down and reused in revision endoscopic skull base cases, even several years after the initial surgery, with excellent coverage of the defect and low incidence of postoperative CSF leak.

Anatomical investigation of the venous system in pedicled nasal septal mucosal flap and its application in nasal skull base reconstruction

Objective: To investigate the distribution and primary drainage sites of the venous drainage system in the pedicled nasal septal mucosal flap, as well as to examine protective measures for the venous system of the nasal septal mucosal flap and its application in repairing the nasal skull base through the anatomical study of the nasal septum mucosal venous system in cadavers. Methods: Gross anatomy dissections were performed on 13 sides perfused fresh frozen cadaveric head specimens. The nasal septum mucosal flap was separated along the perichondrium and subperiosteum, then passed across the vomer, anterior wall of sphenoid sinus, clivus, and towards the anterior edge of vertical plate of palatine bone. Detailed documentation, including photographs, was made to record the morphology, distribution and drainage location of veins of the nasal septum mucosal flap and its pedicle, along with number of sphenopalatine veins. Furthermore, venous injuries resulting from obtaining a pedicled nasal septal mucosa flap were observed. From March 2023 to March 2024, a retrospective analysis was conducted on patients with nasopharyngeal lesions who underwent surgical repair using a modified pedicled nasal septum mucosal flap for venous system protection in the ENT institute and Department of Otorhinolaryngology at the Eye & ENT Hospital of Fudan University. The postoperative endoscopy was employed to assess the viability of the mucosal flap. Results: The veins of the nasal septum mucosa were primarily located in the posterior region, including the vomerine region, anterior wall of the sphenoid sinus, clivus region, and posterolateral wall of the nasal cavity, in a reticular pattern. Perforating veins draining into these bony structures could be observed, although their quantity and morphology varied. Notably, no prominent sphenopalatine veins were identified in 10 specimens examined, while 3 specimens exhibited sphenopalatine veins: one with a small single branch and two with venous bundles. Preservation of the nasal septal vein was possible when dissection was limited to the anterior edge of the wing of vomer. A wider range of dissection increased the risk of veinous injury. In cases where only vascular pedicles at the sphenopalatine foramen were preserved, three cadaveric head specimens retained intact sphenopalatine veins, while drainage veins were completely destroyed in ten other specimens. Fifteen patients with unilateral lesions (8 with recurrent nasopharyngeal carcinoma and 7 with nasopharyngeal radionecrosis) were included in this study. The postoperative reconstructions were carried out using contralateral pedicled nasal septal mucosal flaps. The average follow-up time was 7 months (ranging from 3 to 12 months), and all the nasal septal mucosal flaps survived. Conclusions: The primary location of the drainage vein within the nasal septum mucosa is situated in its posterior region, where it penetrates into adjacent bone structures. Very few sphenopalatine veins pass through the sphenopalatine foramen. Extensive dissection of the pedicled nasal septal mucosal flap may potentially impair the venous system and adversely affect flap survival rates, necessitating further clinical exploration.

Clinical Outcomes and Applicability of Serratus Anterior Muscle Flap With Split Thickness Skin Graft in Thin Resurfacing Reconstructive Surgeries: A Retrospective Analysis.

This retrospective study evaluates the efficacy of the serratus anterior muscle (SAm) free flap combined with a split thickness skin graft (STSG) for thin resurfacing in reconstructive surgery, presenting an alternative to pure skin perforator flaps. It analyzes 14 SAm free flap procedures performed between January 2015 and December 2023. The study cohort comprised 5 women and 9 men, aged 31-80 years, addressing defects caused by infection, malignancy, burn, and trauma, located in various body parts.The study involves harvesting the SAm flap while focusing on anatomical features such as the distinct direction of muscle fibers and the surface location of the vascular pedicle for efficient dissection. It emphasizes the anatomical advantages of the SAm flap, such as robust vascular supply, controlled flap thickness, and preservation of the long thoracic nerve, making it suitable for a range of surgical needs. Complications included STSG loss, partial necrosis, and infection, all managed effectively. Postoperative shoulder function assessment showed no significant impairment.Results demonstrated the successful application of the SAm flap in all cases, with an average flap dimension of 38.21 cm2 and pedicle length of 7.3 cm. The average operation time was 122.1 minutes. The study underscores the SAm flap's adaptability, versatility, and minimal donor site morbidity.It concludes that the SAm flap, in conjunction with STSG, is a viable alternative for thin resurfacing in reconstructive surgery. However, limitations such as the small sample size and procedural variability suggest the need for further research to fully establish the flap's potential in diverse surgical contexts.

Modified salpingopharyngeus myomucosal flap: a novel technique for skull base reconstruction.

Advancements in endoscopic skull base surgery have enabled complex tumor resections, necessitating a variety of reliable reconstructive techniques to repair resultant defects. Vascularized flaps represent optimal options, but frequently used local pedicled intranasal flaps may be unavailable due to tumor invasion or prior surgery. This study applies a modification to the previously described salpingopharyngeus myomucosal flap (Dicle flap) with potential for its use in extensive endoscopic skull base surgery defect's repair. Cadaveric dissections (n = 5) were performed utilizing endoscopic visualization to access the skull base via endonasal and transoral routes. A superiorly based posterior pharyngeal myomucosal flap along the salpingopharyngeus muscle was elevated off the superior pharyngeal constrictors, preserving their vascular pedicles. This combined flap could be 180 degrees transposed to reconstruct clival defects up to the sella turcica. The modified salpingopharyngeus myomucosal flap (Modified Dicle flap) provided approximately 40 cm2 of robust vascularized tissue based on the ascending pharyngeal artery and random posterior pharyngeal vessels. It was sufficiently mobilized to cover extensive skull base defects in the craniocervical junction, sella turcica, and protecting the exposed internal carotid artery segments. The modified Dicle flap offers a viable reconstructive option for extensive endoscopic endonasal skull base defects when commonly utilized vascularized flaps are unavailable. Further research on clinical cases is warranted to investigate postoperative function and refine techniques to minimize donor site morbidity. Not applicable.

Anatomical research and clinical application of multistage advancement in dorsal finger V-Y flap.

To investigate the anatomical basis and clinical efficiency of the advancement distance in dorsal digital V-Y advancement flap. Thirty-four fingers in 11 fresh adult hand specimen were selected, V-Y flap was performed with the digital artery as vascular pedicle, and the advancement distance was measured. The relationship between the distance and extensibility of skin, sliding degree of subcutaneous superficial fascia, angular displacement of digital arterial dorsal branch, elasticity of digital artery was discussed. Two cases were provided to demonstrate the feasibility and importance of this flap. In the dorsal digital V-Y advancement flap simulated on fresh adult hand specimens, the mean advance distance of the middle segment flap and proximal segment flap is 18 ± 0.8 mm and 34 ± 1.7 mm, respectively, and the maximum can reach 24 and 45 mm, respectively. Two cases of dorsal digital V-Y advancement flaps were designed and performed in the dorsal side of the ring finger middle segment and the thumb proximal segment, respectively. The advancement distances were 25 and26mm, respectively. All flaps survived completely and the incisions healed by first intention. The flap texture wasgood, the affected finger was symmetrical, and the activity and sensation restored well. The dorsal digital V-Y advancement flap with the digital artery as the main vascular pedicle can exert four factors for advancement effect, and significantly increase the advancement distance. The operation is simple, the blood supply is reliable, and the postoperative sensation is normal. It is an ideal flap for repairing the digital dorsal defect.

Secondary Reconstruction of Premaxilla With a π-Shaped Fibula Osteocutaneous Flap.

Midface deformities due to oncologic bony defects are often difficult to secondarily correct. The authors herein report 2 cases of secondary reconstruction of an oncological premaxillary defect using a π-shaped fibula osteocutaneous flap. The authors divided the fibula into 3 pieces and made it π-shaped to reconstruct the curvature of the premaxilla. The palatal mucosal defect was closed with a skin paddle. The vascular pedicle was hooked up to the neck vessels either directly or by interposition of vessel grafts. Reconstruction was successful in both cases. The facial appearance was greatly improved, the palatal defects were closed, and the need for obturator prosthetics was eliminated. Immediate bony reconstruction is preferred for premaxilla defects. However, secondary reconstruction with a π-shaped fibula osteocutaneous flap is a feasible option with high potential for improving aesthetic and functional outcomes.

Exendin-4 promotes ischemia-reperfusion flap survival by upregulating Gpx4 to inhibit ferroptosis

BackgroundEffective drugs for preventing or treating skin flap necrosis remain elusive. In this study, we investigated the potential protective effect of exendin-4 against skin flap ischemia-reperfusion injury (IRI) through the inhibition of ferroptosis. MethodA rat abdomen was constructed with an island skin flap, and the superficial vascular pedicle of the abdominal wall was closed using a vascular clamp, which was removed after 8 h. Before surgery, RSL3 and ferrostatin-1 solutions were intraperitoneally injected. After the surgery, subcutaneous injections of exendin-4 were administered daily. The number of inflammatory cells, mean vascular density, collagen fiber content, and apoptosis and ferroptosis indicators were quantified 24 h after reperfusion. Survival, contraction rate, and blood perfusion of the skin flap were evaluated on days 1, 3, 5, and 7 after reperfusion. ResultsThe flap survival rate was significantly higher in the exendin-4 group than that in the injury group, whereas the contraction rate was lower. Compared with the injury group, the exendin-4 group showed less inflammatory cell infiltration, higher vascular density, and less collagen fiber loss. At the molecular level, the exendin-4 group demonstrated opposite or elevated expression of apoptosis and ferroptosis indicators than those in the injury group, with significantly increased glutathione peroxidase 4 (Gpx4). Ferroptosis inhibitors and agonists enhanced and reversed the protective effects of exendin-4, respectively. ConclusionExendin-4 alleviates skin flap IRI by upregulating Gpx4 expression to inhibit ferroptosis. Therefore, exendin-4 may serve as a novel clinical treatment for skin flap IRI.