Ang Zeng

Perineum reconstruction with pedicled anterolateral thigh fasciocutaneous flap

Eighteen pedicled anterolateral thigh perforator island flaps were used for complex perineal reconstructions between May 2003 and May 2005. The patients’ average age was 48.6 years (range, 32 to 64 years), and the average follow-up period was 8 months (range, 2 to 13). In 7 cases, the perforator was septocutaneous and in 11 it was intramuscular. The application of the pedicled anterolateral thigh fasciocutaneous flap is described perineum reconstruction. The size of the perineum defects ranged from 6 × 9 cm to 16 × 17 cm, and the size of the transferred flap ranged from 8 × 11 cm to 18 × 20 cm. All flaps survived. One patient developed minor wound dehiscence in the posterior aspect of the perineal wound because of fecal contamination and skin maceration. The esthetic appearance of the reconstructed perineum was good. Despite a variable vascular anatomy that can give rise to some surgical challenge in raising the flap, the authors conclude that this is a safe and reliable flap for perineal reconstruction.

A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report.

Background: Vaginal reconstruction after tumor resection or in congenital vaginal agenesis remains a challenging area in surgery, with many techniques previously described underlining the continued search for an ideal method. In this preliminary report, a series of patients are presented who underwent vaginal reconstruction using a deep inferior epigastric artery perforator (DIEP) flap. Methods: Between May of 2004 and February of 2005, five patients underwent vaginal reconstruction using the pedicled DIEP flap. Four patients had congenital vaginal agenesis and one had a complete vaginal resection because of a tumor. Results: The flaps ranged in size from 9 × 10 cm to 11 × 12 cm. All flaps survived, although one patient developed a posterior space hematoma that required draining. Of the five patients, two were sexually active and enjoyed satisfactory penetrative intercourse after reconstruction. Conclusions: This series demonstrates that a new vagina can be created from the pedicled DIEP flap and that the reconstruction is reliable, with low donor-site morbidity. The major disadvantage of this technique is the conspicuous abdominal scar.

Latissimus dorsi flap for total autologous immediate breast reconstruction without implants.

Background: The latissimus dorsi flap provides suitable recipient tissue for fat transfer, with a good blood supply and a reasonable volume of host tissue to inject into. The authors present their experience with use of the pedicled latissimus dorsi flap for fat grafting in total autologous immediate breast reconstruction without implants. Methods: From 2010 to 2013, 23 patients underwent breast reconstruction with primary fat augmented latissimus dorsi flaps (21 unilateral procedures and two bilateral procedures). Mean patient age was 52.3 years (range, 39 to 68 years); mean body mass index was 24.77 kg/m2 (range, 21.5 to 28.7 kg/m2). Fat was harvested using the Coleman technique with 10-ml syringes and injected into the adipose layer and muscle fascia of the latissimus dorsi flap skin paddle with 1-ml syringes. Results: The mean size of the harvested skin paddle was 19.7 × 11.04 cm (range, 18 × 10 cm to 21 × 12 cm). Mean operative time was 2.62 hours (range, 2.10 to 3.20 hours) and 4.12 hours (range, 4.10 to 4.15 hours) for unilateral and bilateral reconstructions, respectively. Mean harvested fat volume was 126 ml (range, 90 to 180 ml), and mean injected fat volume was 101 ml (range, 60 to 150 ml). All flaps healed uneventfully, no seroma occurred at the flap donor-site, and no fat grafting–related complications were observed. Conclusion: To the best of the authors’ knowledge, this is the first report in which fat transfer was used to achieve immediate latissimus dorsi flap volume augmentation as an alternative for total autologous reconstruction, avoiding implant-related complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Pedicled thinned deep inferior epigastric artery perforator flap for perineal reconstruction: A preliminary report

BACKGROUND Deep inferior epigastric artery perforator (DIEP) flap has proved to be an effective method in perineal reconstruction. However, a few literatures have reported thinned DIEP flap which yields a better functional and cosmetic result. There are also no clear guidelines on the degree to which a DIEP flap may be debulked of excess tissue before flap viability becomes compromised. In this preliminary report, a series of patients are presented whereby perineal reconstruction was achieved using the pedicled, thinned DIEP flap, based on debulking parameters from our clinical findings. METHODS Between September 2007 and August 2010, 12 pedicled, thinned DIEP island flaps for perineal reconstruction were performed on three patients with vulval or vaginal tumour, five patients with congenital vaginal agenesis and four patients with perineal Pagets disease. The flap was thinned in the plane inferior to the superficial inferior epigastric vein based on the subcutaneous vasculature of the abdominal wall, as depicted by preoperative computed tomography (CT) angiography (CTA) examination. RESULTS Preoperative abdominal CTA can perfectly display the anatomy of DIEP flap. With a sensitivity of 100% and a specificity of 100% (Φ>0.5 mm), it helped in reducing the harvesting time for the flap and in guiding flap thinning. Partial necrosis of the distal flap occurred in a relatively large transverse flap measuring 24 cm×8.5 cm. One patient experienced dehiscence and a subsequent suture was successfully made. The other ten flaps were transplanted successfully without any complications. CONCLUSION This series demonstrates that DIEP flap can be reliably debulked in the plane inferior to the superficial inferior epigastric vein with relatively no risk of necrosis and can be used safely in perineal reconstruction. The abdominal CTA can be employed as an assisting tool to plan the DIEP flap as well as guide flap thinning.

Anterolateral thigh flap-based reconstruction for oncologic vulvar defects.

Background: Vulvar defects after tumor extirpation always require immediate reconstruction. Transferring a skin flap from a distant region may be required for large defects. Although the anterolateral thigh flap has gained popularity in other types of oncoplastic surgery, it has rarely been reported for vulvar reconstruction. The aims of this retrospective study were to evaluate the outcome of anterolateral thigh flap–based vulvar reconstruction and to develop an operative strategy. Methods: Eleven patients with vulvar carcinoma underwent resection and immediate reconstruction with the anterolateral thigh flap between 2005 and 2009. Based on defect type and local soft-tissue quality, four types of anterolateral thigh flap–based reconstructions were performed: unilateral anterolateral thigh flap, ipsilateral anterolateral thigh flap combined with contralateral advancement flap or local flap, fenestrated anterolateral thigh flap, and split anterolateral thigh flap. Postoperative complications were recorded and clinical outcomes were evaluated. Results: Partial flap necrosis occurred in one patient with a fenestrated anterolateral thigh flap for bilateral reconstruction. One wound dehiscence occurred in the contralateral local flap. Two patients had prolonged serous drainage. Mean follow-up was 8 months. One patient developed stricture of the urethral meatus and another had regional metastasis. Conclusion: With careful design, the anterolateral thigh flap may provide reliable and durable soft-tissue coverage for various vulvar defects with good outcomes and minimal donor-site morbidity.

Treatment of divided eyelid nevus with island skin flap: report of ten cases and review of the literature.

Purpose: Three different techniques used in 10 cases of divided eyelid nevus and the results are reported and discussed. Methods: A retrospective study of 10 patients who had undergone treatment of divided eyelid nevus with skin flap between March 2003 and March 2008 was conducted. According to the location, shape, and size of the upper and lower eyelids nevus orbicularis oculi musculocutaneous flap, postauricular superficial musculoaponeurotic system (SMAS)-pedicled flap, or reversal superficial temporal artery (STA) flap was designed to repair the eyelid defects. Results: Ten patients were treated in this series with 10 oculi musculocutaneous flaps, 3 postauricular SMAS-pedicled flaps, and 3 reversal STA flaps. One postauricular SMAS-pedicled flap and 1 reversal STA flap showed distal flap venous refluence (reflux) obstruction and partial epidermal necrosis in the early postoperative stage, but after active treatment, they healed well and needed no surgical revision. All the other flaps survived well. Four flaps showed slight trapdoor deformation needing no revision. No other complication developed during the follow-up periods of 6 to 36 months. All the donor sites were closed directly and healed well with inconspicuous scarring. This series has exhibited satisfactory cosmetic and functional results. Conclusions: Treating divided eyelid nevus with well-selected skin flaps is satisfying with excellent color and texture matching, normal eyelid function, and inconspicuous donor deformity.

Circulating microRNA-194 regulates human melanoma cells via PI3K/AKT/FoxO3a and p53/p21 signaling pathway

In the present study, we analyzed the role of microRNA-194 circulating regulated human melanoma cell growth. We found that microRNA-194 expression was markedly suppressed in human melanoma patients, compared with negative control group. Next, disease-free survival (DFS) and overall survival (OS) of high expression in human melanoma patients was higher than those of low expression in human melanoma patients. MicroRNA-194 overexpression inhibited cell proliferation, induced apoptosis, increased caspase-3/−9 activities and promoted Bax/Bcl-2 of human melanoma cells. Furthermore, microRNA-194 overexpression also suppressed PI3K/AKT/FoxO3a signaling pathway and induced p53/p21 signaling pathway. PI3K inhibitor, suppressed PI3K, phosphorylation-AKT, FoxO3a protein expression and increased the effects of microRNA-194 overexpression on cell growth, apoptosis, caspase-3/−9 activities and Bax/Bcl-2 protein expression of human melanoma cells through the induction of p53/p21 signaling pathway. Taken together, these data indicate that circulating microRNA-194 regulated human melanoma cells via PI3K/AKT/FoxO3a and p53/p21 signaling pathway.

Microsurgical correction of progressive facial hemiatrophy using free anterolateral thigh adipofascial flap.

BackgroundThe etiology of progressive facial hemiatrophy is unclear according to resent research. The diseases lack effective treatments. The purpose of this study was to introduce a technique that restores the cosmetic amelioration effectively using free anterolateral thigh adipofascial flap through anastomosis. MethodsFrom September 1999 to June 2011, a total of 14 patients were subjected to correction with revascularized free anterolateral thigh adipofascial flaps at the first stage. Some of them performed additional procedures, such as dermal fat flap filling, lipoinjection, liposuction, and thinning of the flap, were used for secondary minor deformities after the first-stage operation. The donor sites were closed primarily without skin grafting or other flap transplantation. ResultsAll of the flaps survived, and the effect is stable during the follow-ups. Patients were quite satisfied with the symmetry and plumpness of the reconstructed faces. The donor sites were sutured directly and healed at the first stage; there were no obvious morbidities and dysfunctions. ConclusionsThe anterolateral thigh adipofascial flap can provide adequate tissue with reliable blood supply, pliability, ease of revision, and minimal morbidity and dysfunction at the donor site. It is a safe, stable, and effective technique for hemifacial atrophy.

Upregulation of Serum miR-10b Is Associated with Poor Prognosis in Patients with Melanoma

Aberrant expression of microRNAs (miRNAs) are believed to play a central role in the initiation and development of cancer. The aim of our study was to determine the clinical significance of serum miR-10b in melanoma. A total of 85 and 30 serum samples were obtained from patients with melanoma and healthy volunteers respectively. qRT-PCR was performed to evaluate the expression level of miR-10b in the melanoma cell lines and the serum samples from the participants. Then the clinical significance of serum miR-10b was further determined. Our results showed that the expression level of miR-10b was significantly increased in metastasis melanoma cells and melanoma patients compared to their respective controls. In addition, serum miR-10b expression level was able to discriminate melanoma patients from healthy volunteers as well differentiate melanoma patients at different clinical stage with high accuracy. Moreover, upregulation of serum miR-10b was positively associated with enhanced lymph node metastasis, advanced clinical stage and a shortened survival rate. Finally serum miR-10b was an independent prognostic factor for melanoma. Collectively, our study suggests that serum miR-10b level is upregulated in melanoma and associated with poor prognosis. It may be used as a potential prognostic biomarker for melanoma.

The “Sandwich Therapy”: A Microsurgical Integrated Approach for Presternal Keloid Treatment

Background Keloid therapy remains a great challenge for plastic surgeons, especially when the defect cannot be closed primarily, necessitating tissue transplantation. Here, we introduce a new treatment modality, called the sandwich therapy, for presternal keloids; the sandwich therapy incorporates preradiotherapy, superficial circumflex iliac artery perforator (SCIP) flap transplantation, and postradiotherapy. Methods From December 2012 to October 2013, 12 patients received the “sandwich therapy.” For the protocol, all patients went through 5 days of specific events: the precut procedure, preradiotherapy, resection and SCIP flap transplantation, donor site radiotherapy, and final presternal radiotherapy. Results All the flaps survived completely. No complication was observed during the perioperative period. With a mean follow-up of 12 months, only 1 case was reported with an incisional hypertrophic scar. In all patients, the main discomfort complaints were resolved postoperatively. Conclusions A low-tension or without-tension closure could be achieved with SCIP flap transplantation. The perioperative radiotherapy could further lower the risk of keloid recurrence. The sandwich therapy provides a new surgical approach to presternal keloid treatment.